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KING'S COLLEGE LONDON
INQUIRY
INTO THE
ANTTVARIOLOUS POWER
OF
VACCINATION.
AN
INQUIRY
INTO THE
ANTIVARIOLOUS POWER OF
VACCINATION;
IN WHICH,
FROM THE STATE OF THE PHENOMENA, AND THE OCCURRENCE OF A GREAT VARIETY OF CASES, THE MOST SERIOUS DOUBTS ARE SUGGESTED OF
THE EFFICACY OF THE WHOLE PRACTICE,
AND ITS POWERS AT BEST PROVED TO BE ONLY TEMPORARY.
FROM WHICH ALSO WILL APPEAR, THE KECESSITY OF, AND PROPER PERIOD FOR AGAIN Sl/BMITTING TO, INOCULATION WITH
VARIOLOUS VIRUS. ^, , p c HOSPH
KING'S COLLEGE HUan
MFDICAL SCHOOL By THOMAS BROWN, '^''^
SURGEON, MUSSELBURGH.
Magna est verUas, et premlebit.
EDINBURGH : Printed by George Ramsay and Co. for the Author; AND SOLD BY ARCHIBALD CONSTABLE AND CO. EDINBURGH J AND CONSTABLE, HUNTER, PARK, AND HUNTER, LONDON.
1809.
TO
ALEXANDER MONRO, M. D.
PROFESSOR OF ANATOMY AND SURGERY IN THE UNIVERSITY OF EDINBURGH, FELLOW OF THE COLLEGE OF PHYSICIANS, AND OF THE ROYAL SOCIETY.
Sir,
It is with extreme regret, that, after near- ly nine years experience in the practice of vaccination, I am under the painful neces- sity of confessing, I have almost arrived at that point, which your superior information in the laws of the animal economy, your acuteness of perception, and your accurate observation, enabled you to attain at the commencement of the practice, and to judge so decidedly of its merits.
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vi
Although I beheve, Hke a very great pro- portion of the medical profession, you have not afterwards been able to resist the evi- dence brought forward in favour of vacci- nation, still I cannot in justice to the sub- ject, to the public, to you, and to myself, omit this opportunity of stating, the remark- able terms in which you then expressed to me your opinion of the discovery : " You thought the consequences to the public were so dangerous, that the practice ought to be prohibited by act of Parliament."
I trust that the reasons and evidence con- tained in this work, will appear to you such, as clearly to evince the uncertainty and dubiety, which still hangs over the whole discovery ; and I am fully satisfied, from your high professional situation, your candour, and your anxiety at all times for the attainment of truth, you will perceive the necessity for the thorough investigation of a practice, the consequences of which, in
Vll
a national view, may be so alarming and disastrous. I beg you will accept of this as a small testimony of my gratitude, esteem, and sincere respect. — I am.
Sir,
Your most obedient. Humble servant,
Thomas Brown.
Musselburgh,) l^dMay 1809.)
CONTENTS.
CHAP. I. Introduction, Page 1
CHAP. II. A concise view of the state of inoculation, 20
previous to the introduction of vaccination, . - - CHAP. III. A brief account of the principal circum- stances relating to the practice of vaccination, as ad- mitted by its Avarmest advocates,- - - - ... 32
Sect. I. As given by Dr Jenner, - - - - - ib.
Sect. II. The result of the experience of other - authorities, .-•--......41
CHAP. IV. Consideration of some circumstances con- nected with the practice of vaccination, . - - . 60
I. Source of the affection, ib;
II. The origin of vaccination, - - - * - . 66
III. Is vaccination the same with the casual disease ? 71
IV. Vaccination when first introduced, compared with its present situation, ------- 73
V. Does small-pox resist vaccination ? - - - 76
VI. Can the system be vaccinated repeatedly ? - 79.
VII. Is cow-pox the primary disease, and small- pox merely a modification of it ? - - - - - 82
VIII. Can cow-pox subdue the variolous inflnence, although previously exerted ?....._ 89
CHAP. V. Inquiry how far the phenomena of the vaccine vesicle, warrant the introduction of the great variety of terms used for denoting, the extent of its influence upon the system, - -- -- -- ■...97
I. The virus, - lOO
II. Vesicle, _._.118
III. Areola, ... - 123 .
IV. Constitutional symptoms, . -' - - . 139
V. Tests of perfect vaccination, - _ . . .134 CHAP. VI. Cases, 151
Sect. I. Cases of the occurrence of small-pox after Taccination, . _ - . ......jb.
Sect. II. Cases of inoculation after vaccination, I97 Sect. III. Cases of the coexistence of small-pox and cow-pox, - - . 213
CHAP. VII. Inquiry into the preceding cases, - 221 - • I. That they are to be considered as cases of small- pox, . - 222
II. That they are to be considered as cases of con- stitutional vaccination, 226
III. That these cases afford the most convincing proof, of the antivariolous power of vaccination being only, temporary, 243
CHAP. VIII. Examination how far the tests, and some other objections, can obviate the effects of those cases, where small-pox have occurred after vaccination, . 254 I. The tests of inoculation, and exposure to the
variolous contagion, . TI. Analogy, 266
III. That the number of cases where small-pox have succeeded to vaccination, are not more numerous than those, where small-pox have occurred a se- cond time, - 274
IV. That if such cases do occur, they are always mild, and those of small-pox are on the contrary generally severe, 38O
CHAP. IX. Conclusion, ........ 255
DEFINITIONS.
As this work may probably fall into the hands of those who are not of the medical profession, it may be necessary to give some explanation of the sense, in which a few terms are employed.
By r mcinatioii is meant — inoculation with the cow-pox matter.
By Inoculation^ when accompanied with no other word explanatory of its meaning — inoculating with small-pox matter.
By Vesicle is to be understood — a pock, or small col- lection of fluid, produced from the inoculation of cow- pox matter, and which, in general, retains, in its advanced stage, a more diluted, and less opaque appearance, than the small-pox pustule.
By Pustule — a pock, or collection of fluid, produced either by the introduction of small -pox matter on the point of a lancet, or from the epidemic disease; and which, ia general, ends in the appearance of pus.
The term Vaccine Villus implies — that fluid, or matter contained in the cow-pox vesicle ; and the term Variolous Virus — the fluid contained in the smalUpox pustule.
The terms Vesicle, and Vaccination, are employed more for brcTity, and in contradistinction to the terms pustule and inoculation, as well as in deference to the present fa- shion of treating the subject, than from any conviction of their correctness, and propriety.
By Chicken-Pox and its varieties, are also to be under- stood— the Swine-Pock in England, and the Blebs and Horn-Pock in Scotland.
The term Specific Influence^ is here meant to convey, not only a distinct diseased action of the system, which, while it exists, is supposed to prevent the operation of any other, but also, that, in its consequences, it prevents the repetition of the same disease ; and, in the case of the ope- ration of the cow-pock influence, it is contended, prevents the small-pox also.
ERRATA ET CORRIGENDA.
Page IS, line 13, read the— p. 28, 1. 11, for demands read de- mand— p. 80, 1. 18, delete but also the cows — p. 82, 1. 12,/or con- dently rf«^^ confidently— p. 167, 1. IS, for his read her— p. 174, 1. \e,for , read ;— p. 210, for Case XII. read Case XIII.— p. 220, 1. 7, for areola read areolae— p. 221, 1. 10, /or that readas — p. 242, 1. 15, for recurred read occurred— p. 258, note, /«r where read when.
CHAP. I.
INTRODUCTION.
It is now about ten years since vaccina- tion was introduced to public notice by Dr Jenner ; and notwithstanding its no- velty, and altogether unprecedented na- ture, it received such patronage from the medical profession, and such encourage- ment from the public, as to have consigned inoculation to contempt and oblivion.
This rapid progress will appear more surprising, when it is considered, that the disease for which it was introduced as a substitute, had been known up- wards of a thousand years, and extended
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its ravages to all quarters of" the globe; that the practice of inoculation had also subsist- ed for near a century, and had attained to such extent, and improvement, as to of- fer to every one who chose to avail them- selves of it, an opportunity to cancel one chance in five, against his existence, with only the risk of one in five hundred.
The vaccine practice was introduced, and recommended to the public by its author, as a perfect antidote, and security, against the small-pox, without any exception, or re- serve ; and if properly patronised, capable of banishing variola from the catalogue of human misery.
So great a character, and seemingly sup- ported by facts, and experiment, naturally led every candid practitioner to a trial of its merits; and all who have wrote upon the subject, have acquiesced with the grand re- sults of its author, and have practised, and
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patronised it, with a zeal hitherto unex- ampled.
The advocates for vaccination, therefore, have, in my opinion, very unjustly declar- ed, that a variety of causes have occurred, to discourage, retard, and prevent the ex- tension of a practice, which was entitled to tiie greatest encouragement, from the bles- sings it was capable of bestowing upon so- ciet}^
I must confess, I cannot see the justice of this accusation; for nothing short of com- pulsatory measures were omitted. No soon- er did Dr Jenner announce his discovery to the public, and its merits were examined, than every facility was given to its circula- tion. The rage was extreme, and fashion- able, not only amongst the medical profes- sion, but all classes of society ; so that, in less than two years from its first introduc- tion, one of the most valuable, and ancient improvements in the whole history of me-
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dicine, was almost entirely neglected, and given up. Even the lower orders of the community, seemed to enter into the sub- ject with enthusiasm ; forgot, or laid aside their attachment to old habits; and, not- withstanding its unpleasant name, and ori- gin, vied with their superiors, in promoting, and extending its influence.
As a proof of this, we may only refer to the remuneration granted by the nation to Dr Jenner ; the different societies institut- ed for its encouragement ; the hospitals established for extending the disease, and the amazing number that have undergone the process of vaccination.
It has been also asserted, that it had to encounter the opposition of designing, and ignorant men. It must be confessed, that, at the commencement of the practice, an opposition arose from a few individuals of the profession ; but so far from thinking that it was inimical to the new practice, I
6
am convinced that it contributed not a lit- tle, to increase its reputation, and to extend its influence. Their arguments in general were deemed weak, their assertions unqua- lified, their facts few and insignificant, and upon the whole conducted with such a to- tal want of the true spirit of inquiry, as, hi- therto, not to be considered as any excep- tion to the general rule. They not only gave an easy victory to their opponents, but contributed to the total extinction of all op- position, by creating a terror in every libe- ral mind, at being blended with such a con- temptible minority. I am afraid, however, it will too soon appear, that such opposition ought to have been attended to ; and, at all events, no grounds were afforded, for such unqualified resistance to the production of every species of proof
In my opinion, such opposition was most unfortunate for the public ; for undoubted- ly, so far from its being charged as a crime.
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not only all liberal-minded medical men, but the legislature of the country, and its whole enlightened population, should have seen the necessity for the most positive proof of its efficacy, before they relinquish- ed so beneficial and rational a practice as that of inoculation, and ought to have excited inquiry, and called for information, from all quarters. It was evident,, that Dr Jen- ner's facts were far from conclusive ; they were even contradictory, and it was ac- knowledged, that nothing analogous existed. The two circumstances of resisting inocula- tion, and exposure to the epidemic, were deemed sufficient to overpower all opposi- tion, and do away all contradiction; and every one who could still resist such proof, must be either stupid, or wickedly perverse.
It has been farther alleged, that cases where vaccination has been said to fail, have been sought after, not only with eagerness, \\xi with misrepresentation ; an4 that a de-
7. •
gree of importance has been given them, ■which the circumstances neither justified, nor required. Here we must observe, that there is a strong indication of that arbitra- ry mode of proceeding, which will be found to attend many parts of the history of vac- cination. It seems but little to accord with a good cause, to stifle inquiry, or to be averse to facts. In my humble opinion, it would have been more consistent with judgment, and justice, at the commencement of such an innovation, to have invited every pos- sible information; and particularly every case, where it seemed to fail in giving se- curity against small-pox; for upon these undoubtedly, as the learned, and acute au- thor, of the article in the seventeenth Num- ber of the Edinburgh Review, very proper- ly observes, the practice must stand or fall. Do those gentlemen mean to contend, that there is less merit, or less virtue, in endea- vouring to correct a public error, than in
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propagating what is good, when both par- ties must be supposed to be influenced with the purest motives ? or do they really imagine, that the subject neither admits, nor requires any more proof? They are perhaps not aware, that by such conduct, if they do not become contemptible, they may at least become guiltj'^, and entail trouble, dis- appointment, and danger, upon a very great portion of the human species. I am afraid, too, that the motives of its greatest advo- cates, are not more disinterested, than those of its greatest enemies. The mind of man is composed of curious materials ; not only does system warp the judgment, but having once unequivocally adopted an opinion, and having gone great lengths in propagating it, few have candour, resolution, and ho- nesty to retract. In many professions, but in none more than the science of medicine, is the mind inclined to systematize : As the field is extensive, and difficult of accu-
9
rate observation, the danger of systena is the greater ; a thousand errors may be com- mitted without the least perception of guilt, and hundreds of our fellow creatures may suffer, - without producing the smallest a- mendment.
The admirers of vaccination contend al- so, that it is an operation of great niceoess, and difficultv, and that much mischief has been done by ignorance. This is compara- tively a new doctrine, and has arisen from the same necessity of explaining facts, which ^ire found to be adverse to the practice. The author of vaccination, and others, contended at first for no such difficulty ; on the con- ■trary, such was its perspicuity, and certainty, as even to be safely trusted out of the hands of medical men, and recommended as one of the best means for rendering it universal. But now, according to Mr Bryce, few of the medical profession are capable of con- flucting it with precision, and effect. When
10
he inculcates such intricacy, and proposes such compound plans, he surely forgets that, if really true, they directly militate against the practice, and would be sufficient of them- selves to overturn it. Besides, we shall see Mr Bryce must overlook his test of double vaccination, for if it really possessed what he alleges, the most ignorant, and inatten- tive of the human race, might vaccinate with precision. To those who consider the mystery, and difficulty he has thrown over the practice, and peruses his plan for the extension of vaccination with attention, the idea of a monopoly must spontaneously oc- cur, did not Mr Bryce's well known cha- racter forbid the entertainment of such a thought, even for a moment ; but I must say, that his partiality to this subject has led him too far, and, in his eagerness to rescue It from every imputation, he has thrown a mystery, and intricacy over the practice, couched in terms too vague, and unguarded,
11
at the expence of the rest of his professional brethren.
It now appears, however, notwithstanding the grand character given it by its author, the concurringtestimony of nearly the whole profession, and the evidence in its favour from extensive trials, that the medical pro- fession ought to have proceeded with more caution, and not have substituted it entirely for inoculation, until a few more years had elapsed. It is now admitted, h-om the most undoubted testimony, that there are many cases, where small-pox have taken place af- ter having undergone perfect vaccination, and the Report of the College of Physicians in London, unequivocally admits, that they entertain no doubt of this fact. The grand advocates however of the practice, still con- tend for the contrary, and find a ready so- lution of all possible difficulty, from imper- fect vaccination, constitutional and local symptoms, or that the practitioner must have
12
committed a mistake with regard to the na- ture of the eruption.
If it should prove, however, to be the fact, that persons who have been vaccinated do take the small pox, then the two great objects said to be attained by the practice, must be given up as chimerical; and in place of finding the total banishment of small-pox possible, and the individuals placed in a. si- tuation of security, and ease upon the sub- ject, all who have, and will submit to the practice, must be plunged into the most distressing state of doubt and anxiety.
I have no hesitation in confessing, that I became an early convert, and advocate, for the new practice ; and it is now eight years and a half since I have uniformly advised, and practised vaccination, in which period, I may safely say, I have vaccinated upwards of twelve hundred, and have only had three cases of inoculation, which were at the po- sitive request of their parents. This I per-
13
severed in, until the present moment, not- withstanding I met with several instances where it appeared to fail in giving security, about three years after the introduction of the practice ; a few more about two years ago ; and those which make a part of the present volume within the last six months.
I was favoured with the first virus I used from Mr Anderson, surgeon in Leith, and it produced the disease in such a perfect form, that I have not in anv instance seen it exceeded.
According to the usual custom then, the child (Lieutenant-Colonel Campbell's) -was afterwards inoculated, and a highly elevated tumor, with a little inflammation round its base, but no pustule, was produced. I con- fess from these effects, as they differed con- siderably from the appearances w hich take place upon re-inoculation, my conviction of its security Avas not a little staggered, and I then suggested my doubts of its being a
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complete antidote. I have since, from all ,the trials, experiments, and practice I have had, seen no cause to change my mind; but being satisfied of its powers as abating, and checking the influence of small-pox, if not totally subduing it, I did not think myself ' warranted, upon my own practice and opin- ions, to make any change, or to endeavour to influence others. Within the last six months, however, in consequence of the small-pox making their appearance, not on- ly in Musselburgh, but in the whole vicini- ty, such a number of striking cases have been pressed upon my observation,, and such a forcible appeal made to my senses, that I could no longer resist the conviction, that vaccination, even in the most perfect form, is not only incapable of imparting permanent security against small-pox, but even of retaining the system in that state of impregnation, capable of only allowing it
15
to exercise its influence, to a safe or trifiing extent
With these facts before me, together with the impression they have made upon my mind, I did not feel myself justified in withholding them from the public, and have accordingly hastily drawn them up, in order that no time may be lost for bring- ing forward new facts, which may either confirm, or overturn the practice. In the mean time I shall add, that until the ex- perience of others coincide with my own, I shall not condemn the practice, but at same time, I shall not think myself justified in pressing it, in the way I have hitherto done.
Lest some should be so uncandid as to observe, that from such a great proportion of the cases belonging to me (where small- pox has occurred after vaccination), a strong proof is afforded of their having been impro- perly vaccinated; I have to remark, in addi-
lb
tion to what will be found in its proper place, that it is but natural I should meet with more cases of my own, than of any other person, while I continue to attend to my own duty, more than my neighbours', and ^vhen I never went out of my own profes- sional circuit, to inquire after them. But here all defence is entireljT^ superseded, by the example and declaration of the Royal College of Surgeons in London, who have not hesitated to declare, that every other evi- dence is imperfect and nugatorj^ There- fore, although I could still readily defeat this objection, it would on\y be subjecting myself unnecessarily to the imputation of want of respect and civility' to my profes- sional brethren, to insert more than what was just necessary to prove, that the occur- rence was not entirely confined to my prac- tice.
I can hardly conceive it possible any one will allege, that an unnecessary and im[)ro-
17
per industry has been used in collecting facts. Such an insinuation deserves to be treated only with contempt ; for I ap- prehend, on a point of such national im- portance, it is an indispensible duty to in- quire carefully, and anxiously, after every circumstance in the least connected with the subject
I think it also but justice to myself to declare, that I have never perused a single publication belonging to those who have been called the antivaccinists, and all that I know of their arguments, facts, and as- sertions, is entirely obtained from the works of their determined enemies, and the ad- mirers, and promoters of the practice. Therefore, if my liiind should be supposed to labour under any prejudices inimical to vaccination, they must have been produced by causes, that are generally capable of ex* citing a quite opposite effect ; and whatever objections I now have to the practice, must
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be entirely derived from the statement of the vaccinists themselves, and from my own experience, and observation.
It is perhaps proper to notice, that I care- fully avoided having any communication with the different practitioners by whom the children were vaccinated, being aware of the strong hold that system has upon the human mind, more especially in this very important subject; thinking it best for the attainment of truth, to state with the great- est possible accuracy, the parents account of the circumstances that attended the vac- cination of their children ; notice the ap- pearance of the arm; and give the names of the families, whereby an opportunity is af- forded to any of the practitioners to satisfy
themselves.
With regard to the plan I have followed in this work, as it was not my intention to give any general history of vaccination, I have avoided, as far as possible, entering
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into any detail or discussion, not connected with my present inquiry. All my object is to show, that the most serious doubts are suggested of the efficacy of the practice, not only from the cases which have occurred of small-pox after vaccination, but also from the confused, uncertain, and contradictory State of the principal phenomena of the dis- ease. How far I have succeeded it is not for me to decide ; and whatever error the work contains, I hope the motive of contri- buting my mite to the benefit of the public, the expedition with which it was brought forward, and my other professional duties, will at least plead some excuse.
CHAP. 11.
A CONCISE VIEW OF THE STATE OF INOCULA- t'iON previous to the INTRODUCTION OF VACCINATION.
When the practice of inoculation was first introduced, the ravages of small-pox were dreadful in the extreme ; their pro- gress was marked with desolation and dis- may; and all ranks of society were expos- ed to their effects.
Although, upon an average of years, a greater number may have fallen a sacrifice to that disease, since the commencement of inoculation, in consequence of its affording a constant source of infection, yet still it depriv- ed it of that desolating appearance, and af- forded to all, who availed themselves of the
21
discovery, a complete antidote to its bane- ful effects, imparted perfect satisfaction, and totally destroyed all future anxiety and ap- prehension.
It is now nearly a century since the prac- tice was introduced*; and during the whole of that time, it is even allowed by the keen- est advocates,for vaccination, that there are perhaps not twenty well authenticated in- stances in this country, where those who have undergone inoculation, have taken the natural disease; a fact of the most striking and satisfactory kind.
The extent to which the practice of ino- culation had attained, immediately preced- ing the introduction of vaccination, was, that every individual who composed the ra-. tional, and inteUigent part of society, avail- ed themselves of its advantages ; seized the opportunity of snatching his offspring, from the desperate chance of one in five against his existence, at only the hazard of one in five hundred or a thousand, and nearly the
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same proportion, in favour of preventing any other distressing consequence.
Although inoculation so rarely produced any severe, and permanent bad eifects, yet those who underwent the operation, were fre- quently subjected to many distressing symp- toms. It could not, however, be owing to this circumstance entirely, that the practice was not generally followed. It is evident, that any practice, carrying with it the advan- tages already mentioned, and adopted by the intelligent part of mankind, must have, in the course of so long a period, become universal, had every exertion been made, which the nature of the subject admitted and demanded. Unfortunately, however, the lower classes were allowed to retain their prejudices, from want of attention to use the necessary means for dissipating them, and those who adopted the practice, consol- ed themselves with their private benefits. Keither the Legislature, nor other public
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bodies, put themselves to any regular sys- tem of patronage ; and the practice was left to work its way through so many obstruc- tions, merely with its own advantages, and the occasional exertions of individuals. I thinkthere cannot be the smallest doubt that, . had the necessary exertions been resorted to, it would have been rendered more easy in every particular, and the practice would have become so universal, as to have ren- dered the epidemic disease quite insignifi- cant, if not extinct.
In the practice of inoculation, a virus was used, taken from the disease you meant to combat ; it produced one possessing all the leading features of the original ; it sel- dom or never passed on, without producing less or more of those characteristic symp^- toms, upon which the certainty of its powers were known to depend ; there was no du- biety about the qualities of the virus ; there was no nicety of distinction about perfect
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and imperfect inoculation ; no contradic- tion and confusion about the certainty of constitutional affection ; the practitioner was not reduced to explain facts as suited the peculiarities of the case ; and lastly, it may be safely asserted, without the hazard of contradiction, that after inoculation was ac" complished, the person was found, from every experience, safe against all future at- tacks of the disease, and that not only the parents, but the individuals, were for ever at rest upon the subject.
When it possessed these positive advan- tages, notwithstanding every individual of the profession followed a different method, and no general rules obtained relating to the operation, or after-treatment ; it may be safely concluded, that had the practice been more reduced to a system, and less subject to the fancy of individuals, the average would have been reduced to one in fifteen hundred, or two thousand. That this con-
25
elusion is not too much strained, may I think be safely admitted, when we consider the variety of practice that existed in all the different stages of the disease ; from the in- troduction of the virus, down to the con- clusion of the disorder. It is to be particu- larly kept in view, too, that in the practice of inoculation,' there was little cause for ap- prehending that the symptoms would be mild and inconclusive ; the contrary was the general result, and therefore evidently required the exertions of the practitioner, and by no means allowed such a contra- riety and inactivity of practice.
It is well known that, in the practice of inoculation, some preferred one age, and others inoculated at all ages ; some used virus of any kind, and others only a certain state of it ; some one mode of introducing it into the system, and others a totally dif- ferent; many contented themselves with in- troducing the virus into one spot, while
26
others applied it to more; some preferred one situation, while others made choice of one quite contrary ; some inoculated in one arm, some in both ; and many covered the spot where the virus was introduced during the whole course of the disease, while others exposed it, or did nothing at all.
After the mere introduction of the virus, many were of opinion, that every thing was accomplished ; some that very little more was necessary; and a few that it was proper to watch the whole progress of the disease. Some of those inoculated, therefore, got no- thing under any circumstances, and some got medicine under all situations; some treated the inflarned pustule in one way, some in another ; and many totally neglec- ted it. During the eruptive fever, many trusted entirely to the influence of cold, while others conjoined the assistance of me- dicines. The treatment after the eruption was equally vague and contradictory. If
27
the eruption was so extensive as to make it an object of attention, and the hfe of the patient in danger, many trusted entirely to the influence of cold through the whole course of the disease ; others joined purga- tive medicines only, to a greater or less ex- tent ; many persevered with cold, till their patients' teeth were shivering to pieces, as being the best antiseptic ; while others trust- ed to bark, blisters, and wine ; and few, or none, thought of the warm bath, pedilu- vium, opiates, and cardiacs.
I consider it quite superfluous to point out, particularly, the effects that must have resulted from such opposite practice. I have no hesitation in saying, that those who paid the least attention to the whole progress of the disease, deprived his patient, in the same proportion, of the chance of an easy and safe termination. I can also take it upon me to say, that, by taking virus from a highly in- flamed arm, introducing it in a manner
28
that produces an extensive, deep, or irritat- ing wound, applying plasters, or any other means of producing heat, neglecting local means to moderate the inflammation of the arm, and trusting entirely to cold to mode- rate the eruptive fever, will increase all the distressing symptoms to jan alarming de- gree, and the deaths to one in little more than a hundred. But if, on the contrary, attention is paid to all the peculiarities which art, science, and constitution demands, I can assert, from my own experience, that he wili not lose above one in a thousand.
Before the practice of vaccination was introduced, I had inoculated upwards of twelve years, and, upon a moderate cal- culation in that period, not fewer than from sixteen hundred to two thousand. Out of all this number, of every descrip- tion, only two died, and these were belong- ing to the lowest description of paupers, with large families, crammed into one small
29
space, and small-pox epidemic in the neigh- bourhood. The method I followed, was, using virus when the pustule was only mo- derately inflamed; merely introducing it by one small puncture with the point of a lan- cet, in general on the left arm, using no ap- plications to the part, but a small piece of flannel applied the day following, and kept on, only two davs. The sleeve was then tucked up, and the pustule exposed.
A day or two previous to the eruptive fe- ver, in certain situations, I ordered the whole body to be washed with soap and warm water, and the child to lie as little as possi- ble upon the inoculated arm. Where the inflammatory symptoms and fever ran ra- ther high, I kept the arm particularly cold, ' either with hair powder, or cloths dipt in cold water, and when remarkably inflamed, an emollient poultice was applied, which, up- on being repeated two or three times, en- tirely relieved the patient. Along with
36
these means, I took care to keep the body cool and the belly rather loose. In the latter period of the disease, when the num- ber of the pustules constituted the cause of danger, and that the age, and strength of the patient were unable to maturate, and afterwards to resist the irritation arising from so much matter, either applied externally, or absorbed, I can assert^ from extensive ex- perience in the epidemic disease, that the persevering in exposure to cold is down- right follyy and could be easily shewn to be contrary to the principles of rational theo- ry, as well as common sense. On the con- trary, when I observe the pulse becoming quick, attended with rigors, grinding of teeth, delirium, &c. I instantly order the warm bath, frequent pediluvium, the liberal use of cardiacs and opium, and frequently succeed in rescuing the patient as it were articulo mortis.
CHAP. Ill
A BRIEF ACCOUNT OF THE PRINCIPAL CIRCUM-> STANCES RELATING TO THE PRACTICE OF VAC^ CINATION, AS ADMITTED BY ITS WARMEST ADVOCATES.
Sect. I.
As given by Dr Jenner.
All the leading circumstances which thef founder of" the practice of vaccination has given in his different pubUcations, will be found to be nearly included under the fol- lowing heads.
I. He more than insinuates, the very great probability of the human species being liable to many diseases, in consequence of being domesticated with many animals.
31
From this account of the state of inocula- tion, it was not surprising that the most dis- tressing symptoms frequently occurred, and that death occasionally happened. It is al- so to be observed, that the practice had not improved of late years in this respect, but seemed rather increasing in instances of un- pleasant terminations; and no attempts were made to place it on a more scientific foot- ing. It was in this situation that vaccination made its appearance ; and, from its strong recommendation, great safety, and seeming efficacy, it exploded inoculation nearly in two years after its first introduction, but with what justice, in my opinion, still re-
mains to be seen.
33
II. That he was led to the subject by finding, that many whom he was called upon to inoculate resisted every effort to give them the small-pox, and upon inquiry found, that a vague opinion prevailed, in the district of country wherein he resided, that those persons who underwent a disease known by the name of cow-pox, were con- sidered as secure from the attack of small- pox.
III. In opposition to this conclusion he observes, that upon inquiring at the differ- ent practitioners all round, he found, that from experience they did not consider the cow-pox as affording any security against small-pox, and also, the farmers inform- ed him, such an opinion had only taken place within their own mismory.
IV. That this opposition of facts, and opinions, might be accounted for, from the common people not submitting to inocula- tion at the earlier periods of the practice,
c
34
and of course, the working people in the dairies, were not put to the test of the pre- ventative powers of the cow-pox ; and also from his discovering, that the cows were subject to various eruptions upon their teats.
V. This also, however, was not without contradiction, for he found, that there were many persons who had gone through the genuine disease, and still were subject to small-pox.
VI. That this disease was then only com- municated to the human species, by being accidentally infected from ulcers on the teats, and udders of the cows.
VII. That now from his experience, and experiments, there are the strongest grounds for believing, that the origin of this ulcera- tion upon the teats of the cows, is from the matter discharged from horses heels in the state of disease called grease, and applied by the hands of milkers, or otherwise, to the cows.
55
Vllt. That, by inserting this virus with the point of a lancet under the cuticle, a pustule is produced, attended with such circumstan- ces, as not only to resemble the aflPection produced from the application of the virus to the hands, or otherwise of the milkers, but also to produce the same result, viz. the complete security against the infection of small- pox.
IX. From the appearance that took place on the first case of vaccination by Dr Jen- ner, he hailed, and felt satisfied, of the com- plete success of his new practice.
X. That the peculiarities of vaccination are the following; a superficial suppuration, of a circular form, with edges more ele- vated than its centre, and of a colour dis- tantly approaching to blue, surrounded with an erysipelatous inflammation, of a greater or less extent. That to these appearances suc- ceed symptoms, shewing an affection of the general system, such as headach, quick pulse,
36
heat, lassitude, pains about the loins and hmbs, vomitihg, and sometimes attended with dehrium. These symptoms vary in their duration, from one, to three or four days, and the disease is generally over by the eighth.
XI. Dr Jenner, in the progress of hi:? work, when detailing cases of various kinds, refers some of the appearances, sometimes to local irritation, and sometimes to consti- tutional affection.
XII. That however some of the appear- ances may be absent, from which the pecu- liar qualities of the disease are inferred, yet still it may, and does possess the antivario- lous power.
XIII. He gives several cases where the per- sons have had the small-pox, and yet have gone through vaccination, even with all the constitutional symptoms, but which, in these cases, he explains away, by saying, that they were merely owing to local irrita- tion, and not to any constitutional affection.
37
XIV. In like manner, where persons have gone through the cow-pox repeatedly, he endeavours to refer all the symptoms fol- lowing the subsequent attacks, to local irri- tation only.
XV. He admits, in one part of his work, of the possibility of a person who has had the small-pox, being nevertheless liable to repeated attacks of cow-pox, and in a- nother, endeavours to get rid of this, not- withstanding the several cases previously brought forward.
XVI. That the instances of vaccination succeeding small-pox, are not more com- mon, than small-pox succeeding inocula- tion, or the natural disease.
XVII. All the cases of small-pox succeed- ing vaccination, which have either occurred to himself, or have been reported to him by others, he positively refers to imperfect vaccination, arising from the use of virus in
38
an improper, or vitiated state, which it readi- ly assumes from various causes, and will on no account admit the possibility of small- pox succeeding to real vaccination.
XVIII. That the causes of imperfect vac- cination are, matter that is, taken from a pus- tule, which never contained any specific vaccine virus; or from its, having lost the specific quality by putrefaction, maturation, or suppuration ; and from matter taken from a pustule produced upon the human skin, by virus generated from a disease in the heels of horses.
XIX. He gives several cases of security against small-pox, arising from the effects of virus from horses heels, and again gives others where it failed, and seems to think it necessary, in order to obtain the perfect disease, that it must pass through the medi- um of the cow, and therefore refers all these cases of contradiction, to imperfect, or vir tiated virus.
39
XX. In many instances he refers those cases of vaccination faiHng, where the in- sertion of the virus is either followed with no effect, or with an erysipelatous inflam- mation, and no pustule, to vitiated virus.
XXI. He describes, in one part of his work, the appearances upon inoculating those w^ho have undergone vaccination, to be, in no instance, more.than a slight erysi- pelatous appearance round the punctured point, attended with no elevation, or pus- tular appearance, and always to disappear in three or four days at farthest. In an af- ter part of his work he allows, that a pus- tule may be produced by such inoculation, and that, too, capable of communicating small-pox to another; but that no constitu- tional affection was produced in the per- son who had been inoculated after vaccina- tion.
XXII. This erysipelatous appearance, he considers as one of the best tests of the sys-
40
tern having been previously rendered se- cure, either with small-pox, or cow-pox, as he says it takes place equally the same in both cases, whichever virus you reinoculate with.
XXIII. That Dr Jenner seems often to have failed in producing the disease, after using a lancet infected, as must be concluded, to his mind.
XXIV. He considers the cow-pox as the original affection, and that small-pox is on- ly a modification of it ; and therefore he considers it as capable of assimulating, weakening, and destroying the variolous vi- rus, even where it may have previously ex- erted itself on the system.
XXV. That it is capable of arresting the progress of scarlatina, and other exanthema- ta, and vice versa ; that it does not seem to exert its influence when the surface of the body is under some cutaneous diseases; that it neither conveys, nor increases, the
41
tendency to other diseases; is perfectly harmless and safe, as a distinct disease ; not possible to be produced but by contact, ac- companied with abrasion of the skin ; at- tended with no pustules, and loses nothing of its activity, and efficacy, by successive vaccinations.
Sect. II.
The result of the experience of other Ait- thorities.
I. It seems to be regarded as certain by some, and flatly contradicted by others, that the matter of grease, taken in a certain period of that disease, is equally capable of producing perfect vaccination, with that from the cow, and probably the purest source of the two.
II. All vaccinists agree in opinion, that the perfect or constitutional vaccination im- parts such complete security against the dis-
42
ease of variola, as was obtained under the practice of inoculation ; and also, on the contrarvi that the imperfect, local, spurious,, or h'regular vesicle, or disease, does not.
III. The evidence by which a regular, perfect, or constitutional vesicle, in the form of vaccination, may be known, are those al- ready noticed as mentioned by Dr Jenner, but allowed to be frequently, if not gene- rally, without the evidence of febrile symp- toms attending it. Nearly every author, laying the greatest stress upori the regular progress of the punctured point to a vesicle, the appearance of which has been already described, succeeded with an erysipelatous inflammation, giving a ring-like appearance, of greater, or less extent, and this succeeded with the vesicle acquiring the form of a scab, of a particular dark colour, and some- what transparent.
IV. There are great variety in the cha- racteristics of" what has been termed the
43
spurious, local, imperfect, or irregular ve- sicle ; almost every author describing a greater or less variety of appearance, form- ing a gradation of the least perceptible dif- ference from what they call the perfect ve- sicle, to that point, where no vesicle what- ever is produced.
V. From all accounts it appears, that there is no one certain criterion, by which the certainty of the success of vaccination, as fortifying the constitution against the in- fluence of variola, can be inferred. Mr Bryce, however, contends, that double vac- cination is that test, and wherever it has been obtained, a complete security may be depended upon.
• VI. It is by no means generally agreed, that the inflamed areola is indispensably requisite to constitute the presence of perfect vaccination. Neither do they agree in the necessity of the presence of constitutional symptoms, to produce the antivariolous
44
power. AH, or most of them admitting, that they have many cases of vaccination, where neither were present, and still the an- tivariolous power seemed so perfect, as to re- sist re-vaccination, inoculation, and contact with persons labouring imder confluent small-pox.
VII. They are also under the necessity of admitting, that even where the pustules are, according to their own opinion, imperfect, or spurious, yet still on re-vaccination, ino- culation, &c. they resist their influence.
VIII. It is even asserted, that genuine virus may be converted into spurious, and spu- rious matter may be converted into genuine, and give the perfect vaccination.
IX. It is generally understood, that the vaccine pustule differs m toto, in its struc- ture, from the variolous.
X. It is unanimously agreed, that al- though a rash sometimes attends vaccina-
45
tion, 5^et in no instance are there any pus- tules.
XI. It is now generally allowed, that the common period of the duration of vac- cination, is seldom under from nine to twelve days.
XII. In general all practitioners prefer the virus in a limpid state, taken from the fifth to the ninth day, and allow the virus that flows first to be the strongest. But it is also admitted, that the perfect disease may be given by virus taken even to the four- teenth day, after every limpid appearance is gone, and evidently in a state of viscidity and suppuration. Mr Bryce, with a few followers contend, that the scab is capable of giving the perfect disease, and to the same certainty, as in its most active limpid st^te.
XIII. All agree in the difficulty of keep- ' ing the virus any time in a state of such activity, as to depend upon its producing
46
the desired effect. It is, however, asserted, that the scab retains its power of imparting the perfect disease many months.
XIV. It is also universally acknowledged, that there are many instances where the practitioner fails to give the disease, although every thing has been obtained to his own satisfaction; and the instances are numerous, when placed in other circumstances.
XV. It is almost universally admitted to be quite safe, and mild, communicates no other disease, and can only be co iveyed by inoculation, or a process similar to it. A few of the most violent opposers of the practice have contended, that it is capable of producing several new, wonderful, and dangerous diseases.
XVI. It is asserted by Jenner, and others, that not only exanthemata, but also chronic affections of the skin are unfavourable to, and resist vaccination ; while others con-
47
tend, that vaccination may be perfectly ac- complished under such situations.
XVII. It is contended strenuously by near- ly every author, and by almost every prac- titioner, that it is a perfect antidote against the small-pox, if the disease is properly com- municated ; and Dr Jenner, and his relative Mr G. Jenner, positively assert, that they have not had one instance of failure in their own practice. They all therefore, and with- out hesitation, refer the whole of them that have been brought forward, to the sweeping power of imperfect vaccination, or to the blindness, and stupidity, of the medical practitioner, who could not distinguish the difference between small-pox, and chicken- pox, a rash, or bug-bites.
XVIII. It is generally admitted also, that the two diseases may coexist ; that is to say, that you may have a perfect vaccine pus- tule, while the body is under the influence of variola, and covered with pustules; and by
48
taking virus from each of the two sources, you will propagate the two diseases distinct from each other. At the same time it is also acknowledged, that they frequently subdue each other, depending upon the priority of their effects upon the system.
XIX. It is asserted by many, that there IS no such disease produced by the mixture of cow and small-pox virus, as that called hybrid, or in other words, a distinct infec- tion, partaking of the nature of both.
XX. In most authors, there are srreat variety in the account of the appearances from inoculation after vaccination, as well as in cases of re-vaccination. It is now pretty generally understood, that upon inoculation after vaccination, you may produce tu- mors, less or more attended with a pus- tule, sometimes resembling a small vesicle, or an elevated tumor, and sometimes a distinct pustule, with more or less virus in it, but in general very little ; and this rip-
49
pearance, sometimes surrounded with a large, and highly inflamed areola. Uporl using the virus contained in this pustule, the small-pox have been communicated.
XXI. All the advocates for vaccination contend, that its antivariolous power is not of a temporary nature, but permanent, and if the practice is persevered in, and becomes universal, it must infallibly eradicate the small-pox. But those who have been called the antivaccinists, have contended, that it either possesses no antivariolous power, or that it is merely temporary.
XXII. There are perhaps, upon an average, about a hundred well authenticated cases, where vaccination has been communicated from the cow to the milker, in what is cal- led the natural way, resisting the small-pox ; and in the way of inoculation after vacci- nation, there are upwards of a hundred thousand.
50
XXIII. Dr Woodville has inoculated many- thousands in the space of six months after vaccination, and they all resisted the infec- tion.
XXIV. It is asserted, that in those instan- ces where small-pox have taken place twice, that the second attack is always very severe, and very frequently fatal.
XXV. It is supposed by some, that about one in sixty is capable of resisting vaccina- tion, while others contend, that all may be made to undergo the disease.
XXVI. That, when the practice of inocula- tion was introduced, there was an equal hue and cry raised against its efficacy, and nearly the same objections as against the practice of vaccination.
XXVII. The very able report of the Lon- don College allows, that there is nothing analogous to this discovery in nature ; also, that there is sufficient evidence where the antivariolous power of vaccination has fail-
51
ed, although it seemed to be communicated in its most perfect form ; but that these cases are comparatively few, and by no means capable of overtvrning the immense mass of evidence, brought forward in its fa-^ vour : indeed, those cases of alleged fail- ure, not being greater than the proportion of deaths arising from inoculation. That, where such cases have occurred, they have uniformly varied much from the usual seve* rity of small pox, and assumed a very trifling appearance.
XXVIII. The College also concludes, that they are equally safe from the epidemic small-pox, as well as from the inoculated ; and observe, that towns and villages have resisted the natural small-pox. They scout the idea of its being only a temporary se- curity, not only upon the grounds already before them, of a practical nature, but also from analogy, of which they add, that there is nothing similar in nature.
52
XXIX. The disease, too, when contracted by milkers, has been subjected to a long test; as they allege, there are no instances where they have not resisted the small-pox.
XXX. The College conceive the practice of vaccination to be as completely establish- ed as the nature of such a question admits, and look forward to the period when all opposition shall cease, and the ravages, if not the existence of small-pox, shall termi- nate. ,
XXXI. The Medical Council of the Jen- nerian Society admit, that a few cases have been brought before them, where persons have taken the small pox, after having pas- sed through the cow-pox in a regular way ; but endeavour to remove the objection, by adding, that they have also cases, supported by evidence equally strong, where persons, after having regularly passed through the small-pox, either by inoculation, or the epi- demic disease, have had the affection a se-
53
cond time, and such second attack is in ge- neral yery severe, and often fatal ; whereas, when it has appeared after vaccination, it has been always so mild and trifling, as even to render its existence doubtful.
XXXII. The Royal College of Surgeons in London admit, in their report, of fifty-six well authenticated cases of small-pox occur- ring after vaccination, besides what they re- jected, upon the ground of not having been vaccinated by the surgeon Avho reported the facts reiating to the attack of small-pox.
XXXIII. In the seventeenth number of the Edinburgh Review, there is a most excel- lent, comprehensive, and distinct view of the subject, where, in addition to the parti- culars already observed, are the following circumstances ; They think there are about twenty well authenticated instances, where persons have had the small-pox after having gone through inoculation regularly, and al- lege, that there are not ten well authenti- ■
54
cated cases of small-pox occurring after per- fect vaccination ; although, from the report of the Medical Council, they observe, there are nearly as many have undergone vacci- nation, as have been inoculated since the commencement of the practice, with this additional circumstance, that a very great proportion have been subjected to inocula- tion after vaccination ; thus, in their opi- nion, subjecting it to a severer test.
XXXIV. The Reviewer alleges, that the greatest number of failures took place pre- vious to the year 1802, at which period vac- cination came to be more accurately un- derstood, and practised, in consequence of Dr Jenner's additional information. They also add, that they may conscientiously con- clude, that it gives a security at least equal to the old practice of inoculation.
XXXV. Dr Adams, physician to the inocu- lation hospital in London, has published up- on this subject, and endeavours to shew,
55
from the laws of morbid poisons, and expe- riments, that the vaccine and small-pox vi- rus are the same. His opinion is founded upon the circumstance, that if mild cases of small-pox are used for inoculation, you will always produce a pustule, making a near approach to the vaccine vesicle, and, in a great proportion of these cases, no pustular eruption.
XXXVI, The Doctor also assumes, as a settled point, that no two local or constitu- tionaldiseases will continue at the same time, in the same place, or in the same constitu- tion. He then proceeds to state, that if you inoculate to-day with chicken-pox, and to-morrow with small-pox, that the inocula- tion from the latter will remain unaltered, until the chicken-pox has completed its course ; or if you introduce vaccine virus when the system is under the influence of measles, or chicken-pox, the same interrup- tion will follow. He concludes, therefore,
56
that both cow-pox and small-pox are simi- lar, and are equally different in their na-
^ ture from measles or chicken-pox. But if we inoculate and vaccinate together, or vac- cinate one day, and inoculate two or three days after, or inoculate first, and then vac- cinate, both begin and go through their usual course, without any other alteration,
^ than that the latest pustule or vesicle would be somewhat smaller.
XXXVII. Mr Bryce, one of the surgeons to the Edinburgh inoculation hospital, and who has published more than once upon the subject, agrees with the principle, that no two opposite actions, whether local or con- stitutional, can exist at the same place or time. He also is decidedly of opinion, that small-pox and cow-pox are two distinct and different diseases.
XXXVIII. Upon going through his works, we find, at page 43, two cases of Nelson's children, where the small-pox made their ap-
57
pearance to a considerable extent, on the eleventh and twelfth days from vaccination, although the vesicle and areola were per- fectly characteristic of the constitutional in- fluence, upon the ninth day from vaccina- tion, and continued to be so during the whole of the eruptive fever, and followed afterwards its usual course ; also, at page 192 and 194, he gives two cases which oc- curred to Mr Gillespie, and which he also had an opportunity of seeing, where the small-pox in one of them made their ap- pearance ten days after having been vac- cinated, but no areola had taken place pre- vious to the eruption. When the fever went off, and the eruption became distinct, which w'as on the eleventh day from vaccination, an areola then made its appearance ; and, as the child had undergone the double vac- cination, an areola also took place in it, at the same instant Avith the areola of the first; both continued for two days. In the other.
58
the eruption took place on the eighth day from vaccination, and, in two days after this^ the inoculated vesicle was attended with an areola, and was admitted to be in every •way characteristic of cow-pox, and within this areola, several small-pox pustules ex- isted, which advanced regularly to suppu- ration.
XXXIX. In No. VT.of his Appendix are to be found several cases, where both vaccine and variolous virus were introduced in the way of double inoculation, and a few days after the primary vaccination ; from all of which it would appear, that the constitu- tional influence of vaccination hurried the second vaccine puncture, but had no effect upon the variolous, which however arrived at maturation at its ordinary period, but no surrounding inflammation, or pustules.
XL. He also states several cases of ex- periments, where it would appear, and which he says shews distinctly, that if you vacci-
59
nate a day or two previous to introducing small-pox virus, you will uniformly find, that the variolous pustule proceeds not only slowly in its progress, but its size and period of maturation considerably diminished.
CHAP. IV.
CONSIDERATION OF ISOME CIRCUMSTAIfCES CON- NECTED M'lTH THE PRACTICE OF VACCINA- ^ ■ TION.
Before we proceed to examine the phe- nomena more immediately connected with the process of vaccination, it may be ne^ cessary to notice a few circumstances re- lating to the practice, as they will enable us not only to form a more correct idea of the state of the whole discovery, but also assist us materially in deciding the extent of the antivariolous power of vaccination.
I. — Source of the Vaccine Afection. Dr Jenner, most unfortunately in my opi- nion, introduces his subject with the ob-
61
servation, that the human species are sub- ject to many diseases, from their domesti- cation with other animals; It was impos- sible that the Doctor could mean any ac- cidental affection; such as rabies canina, or any other disease, or distress, proceeding from wounds, bites, or ulcefs, produced from having contact with their sores, or from their being capable of exciting a variety of distressing affections from terror. He un- ,questionably conveyed the idea, that we were liable to be influenced by many dis- eases to which they might be subject, by their acting from contagion.
I am warranted to conclude, from the au- thority of the whole College of Physicians in London, and I believe I may add else- where, that there is no foundation whatever for this insinuation ; for it is expressly al- lowed, that there is nothing analogous to it hitherto known. Whether the Doctor, therefore, dropt the idea from mere inatten-
62
tion and accident, or from a design of mak- ing such an unheard-of proposal gUde more easily down, I shall not pretend to say ; but certainly, as the subject now stands, when every phenomenon belonging to it is en- veloped in doubt and contradiction, we are warranted in entertaining the opinion, that Dr Jenner himself was not exactly at rest upon the subject.
In his first publication, he suggested the probability of the vaccine affection being derived from a matter discharged from the heels of horses, in a state of disease called grease; and brought forward, in proof of this, several cases, where security against variolous contagion seemed to be imparted. He also stated others quite of an opposite tendency, where the small-pox succeeded to the equine affection, in a greater or less extent, and seemed inclined on the whole to conclude, that it was not of equal efficacy with the vaccine affection.
63
111 an after publication, however, he seems ra- ther to think them the same, and endeavours to reconcile this difference of opinion by stating-, that the virus changes its quahty from various causes, so as to have lost ei- ther entirely, or nearly^ all its antivariolous power, or to have only produced local ef- fects.
This opinion was supported by Dr Loy, by a series of experiments, and it was contradicted by Drs Pearson, Woodville, and others. It seems now, however, to be the most prevailing opinion, that this matter from horses heels is really the source of the vaccine disease, and equally capable of pro- ducing the antivariolous process; and I con- fess, from €very thing I have read on the subject, I am inclined to think it distinctly ascertained. If this is the case, it ouaht now to assume the title of the equine or horse-pox; and the name of cow-pox stands in the same predicament, as if it were
64
to receive its name from the human species, or any other animal it was appHed to by inoculation.
Those, however, who contend for this source of the disease, require, that the virus must be in a particular state, which can on- ly be found at a certain stage of the disor- der, and, if used in any other, it will not communicate the antivariolous power to the constitution.
Here> at the very outset, we meet with the most glaring uncertainty on a very import- ant and fundamental point, and a principle started of such uncontrouled and extensive application, as to be capable of defeating every species of proof that could possibly oc- cur, inimical to the practice. Indeed, so sen- sible do all vaccinists seem to be of the great delicacy of this part of the subject, that they seem from sympathy inclined to draw a veil over it, for the ultimate safety of the whole practice.
65
We may however observe, that it is not a httle remarkable, if this equine virus should possess the power ascribed to it, that the effect should be confined entirely to so small d district of country, when it is known, that the original disease exists over the whole of Europe, and perhaps the globe. It is farther to be remarked, that the phenomena of the disease of grease affords no reasona- ble foundation for ascribing to it such pow- ers. So far as our experience goes^ it seems produced by no epidemic, is incapable of communicating' itself by contagion, either to other horseSj or to the human species; it even does not seem to possess much activity, tor its effects are most undoubtedly rare in proportion to its frequency ; and the disease is attended with no other eruption, or exter- nal appearance, and certainly bears not the smallest resemblance to the vaccine vesicle, whether produced casually, or intentionally; and none of the circumstances^ except in the
E
66
mere production of the vesicle, have the Smallest affinity, or resemblance to small- pox : to all these we may add the fact, that many cases have occurred, where the dis- ease from this source failed to give the smal- lest security.
From these circumstances I think we are warranted in concluding, that if this matter of grease possessed such properties, we must, from the universality of its exis- tence, have become long ago acquainted with the feet ; and also, if it is really the source of the vaccine affection, and equally capable of producing- the disease, we have no reason, either from its phenomena or ef- fects, for concluding, that it can impart any security against variolous contagion.
IT,— 77ze Origin of Vaccination. The Doctor states, that he was led to the discovery, from t^e well known fact in Glo- cestershire, that those who had undergone
67
a disease known by the name of cow-pox, were uniformly considered as for ever free from the influence of small-pox. Here how- ever, unfortunately, the Doctor is not void of contradiction and difficulty, for it happens, that, in inquiring into the truth of this gene- ral rule, he meets not only with many cas^ ^ where they have suffered an attack of small- pox, after having gone through the casual disease, with constitutional symptoms ; but also, that such an idea of security was of very late date ; that many of the old farmers never heard of such an opinion ; and that all the surgeons to whom he applied in that neighbourhood, contradicted such an idea on the score of experience.
The Doctor endeavours to get over these difficulties, by finding out, that there are se- veral other eruptions to which cows are lia- ble, which may be readily mistaken for cow- pox. Here again the Doctor meets with the most irreiistible opposition, and is obliged to
68
confess, not only that these different species of vesicles are often not to be distinguished from the vaccine, but also, that there are many well authenticated cases, where the genuine disease had failed to give security.
One sourceof relief still remained ; it was now found that the matter in the genuine vesicles might have undergone such a change, as either to contain no vaccine vi- rus, or at best but little, and that so much weakened, as not to impart any, or at best an imperfect security, against small-pox. This change was said to be effected, when the virus in the vesicle lost its fluid and limpid appearance, and became more and more inert, as the vesicle decayed; and in its last stages conceived it to be totally un- fit for use, either from its viscidity, or puru- lency.
Here I dare say the Doctor thought him- self impregnable, but experience has proved him miserably deceived; and all former ab-
69
surdities and contradictions were swallowed up in the opinion started by Mr Bryce, who gravely asserted, upon the most positive facts, that the scab was equally capable of giving the genuine, and constitutional disease, with the most hmpid virus, ^nd superior to it when viscid, and somewhat opaque.
In answer to these reasons of the Doctor, it may be first observed, that it is by no means a slight objection to any practice, if it is at- tended with so many doubtful circumstan- ces, as to render it not a little difficult to ar- rive with any precision at the ascertaining the existence of the real disease. Besides, it by no means appears, from the considera- tion of the phenomena, as they are now more clearly understood, that the character^ istics of the vesicle are to be depended upon. Also, it is to be observed, that the number of cases which the Doctor brings forward, in favour of its resisting the variolous contagion for any length of time, are by no means so
70
numerous, as that the cases of an opposite tendency do not form a very serious con- trast ; for it is to be particularly remarked, that in such an extent of country, and where the practice of milking appears so universal, so few well-authenticated instances can be found of permanent security being afforded, as not perhaps to exceed a hundred. For these reasons, therefore, it is difficult to con- ceive, that if it really possessed this power, it would not have been more generally re- marked, as abundance of instances could not fail to have occurred, all over the world.
I shall pursue this subject no farther at present, but content myself with observing, that it appears to me an unwarrantable con- duct, in inquiring after truth, to produce circumstances, and theories, by which every possible case that can militate against the practice must be defeated, and all attempts at a fair and philosophical inquiry renderecl abortive.
71
III. — Is Vaccination ike same with the Casual
Disease f
Dr Jenner next proceeded to realize all his conjectures, by introducing the vaccine virus on the point of a lancet, in the wa>^ of inoculation, from which a vesicle was pro- duced, characteristic not only of cow-pox, but having such a resemblance to small-pox, as immediately to impress the Doctor's mind with the attainment of his labours. This was farther confirmed by reinoculating them with small-pox virus, and exposing them to the epidemic ; both of which they wt re found to resist. The only differences to be observed between the disease communicated by inoculation, and casually from the cow, were, that the vesicles are less in size, and the effects produced upon the system are not only much less severe, but in general not perceptible. Still, however, it is asserted, that it is attended with the same security as from the casual form of the disease, and
. 72
is found to resist the usual tests, No erup- tion was found to take place over the body, no danger found to accompany the disease, and no bad consequence to follow it. From such a character, it was soon submitted to the most extensive trials, and fouqd to an- swer the account given of it by the author. Such was the industry used by practition- ers in general, that more have been vac- cinated in eight or nine years, in this coun- try, than were inoculated in nearly a cen- tury ; and upwards of a hundred thousand have been made to submit to inoculation after having been vaccinated, and a great number were also freely exposed to infec- tion.
From such positive testimony in its fa- vour, every liberal mind could not hesitate to assent to, and adopt it ; and all openly, or tacitly, acquiesced in this truth, that, what- ever power casual vaccination might have, itwas evident that, in the way of inoculation.
73
or, as I have always used the term, vac- cination, it imparted a perfect security, and shielded the constitution as completely against the variolous influence, as the smallr pox itself. .
Although I admit that this conclusion was nearly fully warranted by the tests, yet I contend, that the other contradictory circum- stances attending the history of the affection, ought to have excited a degree of doubt, and checked our ardour, in the universal propagation of a practice, so opposite to the laws of nature, and the animal econo- my.
IV. — The State of Vaccination wJien first intro-' duced, compared xvitk its present situatioJi.
Upon the introduction of the practice by Dr Jenner, a description was given of the vaccine vesicle, and the phenomena attend- ing it, which was not only at that time fieemed sufficient by himself, but also for
74
some time after by others, to characterize and distinguish, not only its local existence, but also of its having exerted its antiva- riolous influence. In addition to this fa- cility of ascertaining the existence of the disease, in the author of the practice, and other writers upon the subject, such was the opinion entertained of the simplici- ty, and certainty, of propagating the dis- ease, that it was recommended to put the practice, even into the hands of clergy- meiiy and females, in order to secure more rapidly to society its beneficial effects.
But not only were the characteristic phe- nomena, and existence of the disease so ea- sily understood, but also it was stated by the Doctor, that constitutional influence did not seem necessary ; for that constitutional symptoms were merely the effects of local irritation from the vesicle. It was also gravely declared, that the same constitution was liable to repeated constitutional attacks
75
of the disease, and that, although those who had undergone vaccination, resisted the ef- fects of variolous contagion, yet those who had been subjected to small-pox, did not re- sist the vaccine influence.
Whether it was observed, that some of these phenomena were quite irreconcilable in point of theory with the pretensions of the new discovery ; that some cases were dropping in of a contradictory nature ; or that experience obliged iis to add several new, and important circumstances, to the history of the disease, I shall not pretend to determine ; but in a few years after the in- troduction of the practice, a genuine, and spurious ; a regular, and irregular ; local and constitutional vesicle, were found absolutely indispensible ; not only did vaccination re- sist small-pox, but small-pox resisted vacci- nation. Vaccination was found to be capa- ble of being communicated only once con- stitutionally, Jind that every other instance
76
must be local. That cow-pox was the pri- mary disease; that small-pox was only a modification of it ; and that it was capable of subduing the influence of variola, al- though previously exerted.
As we will have occasion, in another place, to attend to the variety, and confu- sion, which accompany the characteristic ^phenomena of the disease, as well as the doubt which attends the knowledge of its local and constitutional effects, we shall proceed to notice the few remaining pecu- liarities, which the vaccinists afterwards con- tended were uniform results of constitu- tional vaccination.
V. — Does Small-pox resist Vaccination f
Dr Jenner unconsciously created a most serious objection to his ncAv discovery, in his first communication to the public, by acknowledging', that although the constitu- tion, after having been vaccinated, was se-
77
cured against the influence of small-pox, yet still a person who had undergone the variolous contagion, was liable to the influ- ence of vaccination.
It was not difficult to detect the shade which this assertion threw upon the cre- dit of the discovery ; — a very partial ob- server would naturally require, that the proof should in this particular be recipro- cal. Accordingly this was in a short time readily given up, and the fact stated to be (notwithstanding symptoms denoting a constitutional derangement were allow- ed to have been present), that such affec- tions were merely local.
From every proof which this point has yet been capable of^ it would appear, both upon the authority of Dr Jenner and others, that many cases have occurred where vaccination has taken place in the casual way, after the occurrence of small- pox, and attended, too, with constitutional
78
symptoms; but they allege, that all the dif- ferent symptoms were comparatively milden Also, by intentional vaccination, the most perfect form of the disease has been produced after small-pox; but they insist, that in these particulars it does not differ from the vario- lous affection, as they allege it is equally cer- tain you may obtain such appearances from reinoculation. This assertion, I can safely say, does not accord with my experience; for I have never, in any one instance of reinocu- lation, been able to obtain any thing like a pustule, and in general never more than an inflamed point, almost constantly beginning to decay by the fifth and sixth da}^ and totally disappearing by the eighth. — And in the casual way it is equally conclusive ; for although the disease is universally se- vere, and highly epidemic, and the ex- posure to its local effects impossible to be avoided, yet the instances of local pustules are extremely rare, and a repetition of the
79
constitutional affection so uncommon, as not to afford, ever since the appearance of that disease in this country, twenty well authen- ticated instances. If this is contrasted with those cases allowed by Dr Jenner, and others, together with what might have been brought forward by more diligent inquiry, and these, coupled with the small portion of country in which the disease is known, it must be allowed, that the two cases do not afford any grounds for a pa- rallel,
VI. — Can the System be Vaccinated repeatedly f
Here, too, the Doctor erred most egre- giously. In his first publications he admit- ted, without reserve, that persons were again and again susceptible of this affection, and although it afforded protection against small-pox, yet it did not resist its own fu- ture influence.
80
It was not difficult to detect the serious operation of this assertion upon the fa:ith of the whole practice, and accordingly it was soon retracted, and amended. It was now found, not only to resist its own future in- fluence, but even to the same extent as small-pox, and recourse was had to those omnipotent harmonizers of discord, local and constitutional iiifluence.
In objection to this amendment, we must observe, that it is impossible to grant, that at one period a disease is local, and at ano- ther constitutional, if we find it existing un- der all the same appearances, at each period. That Dr Jenner's cases are not only decisive of the fact, tha;t both milkers and cows are sus- ceptible of frequent repetitions of the disor- der, with tlie same phenomena, but also the cows ; and it is well known that horses may have the disease over and over again. Be- sides, Drs Pearson, Willan, and others, prov- ed clearly, that a genuine vesicle may be
81
produced repeatedly, if the operation is per- formed at the distance of some months from the first vaccination. I have also had fre- quent opportunities of observing this ; and I may add, it is quite in opposition to om* experience, both of reinoculation, or any information we can collect of the recurrence of the natural disease.
From these considerations we may safely affirm, that although the constitution has been influenced by the vaccine virus, it re- mains susceptible of not only admitting it to reproduce a perfect vesicle, but even of being affected again, and again, with such symptoms as were found to exist in the first attack, and which were then declared to be constitutional ; but that it also be- trays phenomena, resembling that of any other virus, having no affinity to those ex- anthemata, capable of exciting any perma- nent constitutional influence.
F
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VII. — // Coxv-pox the primary disease, and Sviall-po.v merely a modification of it ^
Dr Jenner's rage for systematizing, and ^ giving such unlimited powers to his favour- ite oifspring, ought to have been a great source of suspicion to every one capable of the least reflection, and should, in my opi- nion, have been a chief cause for renewing an inquiry, which I am afraid will end in the overthrow of all those flattering prospects, which were once, and even are still, so con- dently asserted, to be the consequence of its universal adoption.
In examining the history, and pheno- mena of the two diseases, we can fmd no other reason for this conclusion, but that it seemed to resist the influence of small-pox; for whether we consider their history, or phenomena, they have not the most distant resemblance. Small-pox have been known in this country for a thousa,nd years, and how long in other quarters of the
83
world is uncertain ; they are also universal ; are a disease of the most severe, loathsome, and dangerous description ; highly contagi- ous; and admitting of no other variety, but in the severity of their symptoms, and always retaining their characteristic phenomena. — Whether propagated by contagion, or by ino- culation, they almost uniformly produce Con- siderable fever, and other distressing symp- toms, which are also, to a greater or less ex- tent, followed with a characteristic pustular eruption. The cow-pock, on the contrary, is only known in one small county of Eng- land, and no where else on the whole globe ; although proceeding from a source, which so far as I am informed, is known in every quarter of the world. Whether casual, or intentional, it varies considerably in its lo- cal effects ; and never produces any other change upon the constitution, but what may be attributed to the effect of the vesicle ; it is also, in general, never attended with any
84
other eruption but what takes place from the topical effects of the virus, and cannot be propagated by contagion. In addition to these objections, there is one material circum- stance to be mentioned ; that, although you^ can produce the vaccine vesicle in its most characteristic form, by inserting the vaccine virus taken from the human subject into the udder of the cow, you cannot produce the small-pox pustule, by introducing the variolous virus.
Some of the experiments, however, men- tioned by Dr Adams, and stated in a former part of this work, would seem to give some countenan,ce to the opinion that they were similar. I apprehend, however, it is im- possible to draw any inference from those made with what he calls the pearl-pock, because it is a fact, nearly as old as the knowledge of small-pox themselves, that if you take care to expose the individual to what is called a good pock, or, in other
85
words, a mild state of the disease, you will almost uniformly obtain the same result ; and in the practice of inoculation, I have already observed, that if care was taken to use a mild virus, you will not fail once in a thousand cases, with attention to other circumstances, to obtain a favourable re- sult ; but even here the difference is equal- ly the same, for the variolous afiection still retains all its characteristic phenomena.
Dr Adams's next experiments which bear upon the subject, refer to the principle which has been generally admitted, and so far as I know is correct, that no two specific actions can exist in the constitution at the same time.
We must first observe, that there is cer- tainly some inaccuracy in the way in which Dr Adams has stated these results, and that it must have escaped his observation; for it is utterly impossible that he meant to convey, there could be any parallel betwixt the two
86
cases, of introducing small-pox and chicken- pox, or chicken-pox 'and cow-pox, at the same time, when no constitutional disease existed ; and introducing small-pox, or cow- pox, when the system is under the influence of measles, or chicken-pox. I should ima- gine the Doctor meant to state, that if we either introduce small-pox, or cow-pox, when the constitution is under the influence of chicken-pox ; or chicken-pox, when the sys- tem is under the influence of the others, that they will not proceed in their progress. If this is not the case, the first set of experiments are, in my humble opinion, wholly incom- prehensible, and cannot be admitted as proving any thing. I apprehend it can be distinctly shewn, that if you puncture the body with several kinds of virus, they will all advance, until interrupted by the specific action of any one of them ; that this inter- ruption will only take place in those pus- tules that are also capable of producing a
87
distinct specific action ; and that all the others will continue their progress to that state of perfection they are capable of ac- quiring.
But the Doctor farther says, if you insert cow-pox virus either at the same time, or some days after having introduced variolous, or variolous along with, or a few days after the vaccine, both diseases will go through their regular progress, no otherwise modi- fied, but the latest pustule or vesicle being only somewhat smaller. Now this State- ment, together with the evidence before us from other sources, clearly shews, that the two diseases may precede, or accompany each Other ; therefore, if they were of the same nature, and possessed the power of producing the same distinct specific action, we should find, according to the well known fact, that small-pox prevents its own repeti- tion, that no such succession to each other should take place ; and also, that we must
88
either renounce the principle of no two specific actions being capable of existing in the system at once, or conclude, that one or other of these affections, does not possess the power of exerting any distinct specific influence.
We have the most convincing proofs of the accuracy of the principle already men- tioned, in all the diseases known to be ca- pable of exciting a specific action, and that the variolous contagion has hitherto been found to be one, that possessed it in the most complete and extensive form, and that all its characters afford the most convincing evidence of this quahty. But when we in- quire into the history, phenomena, and ef- fects of the cow-pox, every thing is confus- ed, and imperfect, and the actual existence of the disease itself characterized by no circumstance, that can give it the smal- lest pretensions to this quality. It is mild, and insignificant, and when compar- ed with the disease it is intended to ob-
89
viate, and supplant, or with any other of the same description, it seems wholly ina- dequate to produce any action on the con- stitution, that can be considered as strongly, or permanently specific, and betrays pheno- mena common to the introduction of many other matters, which have never been sup- posed to have any thing more than a local eifect. Under such circumstances, then, I apprehend, we are not warranted in reject- ing an established principle, but on the con- trary, we are at liberty to conclude, that cow-pox is totally different from small-pox, and that if such a connection was necessary for establishing the perfection of vaccina- tion, it can look for no relief from this quarter.
VIII —/^ Cozv-pox capable of subduing the Va* violas injiuence, although previously exerted?
This was the ne plus ultra of vaccination ; and, unfortunately for Dr Jenner, this is also
90
relinquished by some of its most sanguine admirers. It is now found from experience, and experiment, that it not only does not possess this power, but that the vaccine ve- sicle may have all its characteristic pheno- mena present, and still incapable of subdu- ing, preventing, or even moderating the Contagious influence of variola ; and there are many cases of the vaccine vesicle going through its most characteristic appearances, after the eruption of small-pox is completed.
In addition to the light which the cases stated by Mr Bryce, and inserted in this work, throw upon this subject, I apprehend those, contained in Section III. Chap. VI. are nearly decisive of the point. To them I have here to add, that soon after the in- troduction of the practice of vaccination, I happened to give a case of lancets to be in-» fected from a vaccine vesicle. The whole were used, and, in one of the cases, I was surprised with a small-pox pustular appear-
91
ance at the arm, attended with much fever, and followed with a considerable eruption. I soon recollected that one of my lancets had been previously infected with small-pox virus, and accordingly entertained no idea prejudicial to the practice, although I was acquainted with Dr Woodville's cases. This accident naturally led me to repeat the ex- periment, and it has been uniformly attend- ed with the same result from which I think we are at liberty to conclude, that as both viruses were introduced together, if the vaccine possessed any such specific power, it ought to have subdued it on that occa- sion. For greater satisfaction, 1 varied the experiment, and introduced each virus by separate punctures ; the result was, that, in every case, the disease was variolous, al- though the vaccine vesicle had obtained, not only the characteristic appearance, but was attended in every case with a distinct areola, to its full extent, which, in manv
92
cases considerably anticipated the small-pox pustule.
The experiments, however, of Dr Adams and Mr Bryce, upon this point, are in direct contradiction *. Mr Bryce contends, that.
* Dr Willan also mentions the result of experiments madei by inoculating with vaccine and variolous virus at the same tiincj or at the distance of some days from each other. He says, that the result was uniformly variolous fever and erup- tion, and that these consequences generally ensued, even where the variolous virus was inserted a week after vaccina- tion ; but if inoculation was performed at the distance of nine days after vaccination, it produced no eifectj He observes, however, that the eruption appeared modified, seldom going through the progress of a variolous pustule, and also, that the cow-pox vesicle seemed so far influenced, as to be both smaller in size, accompanied with a slight areola, and the whole of its progress impeded. Notwithstanding these ap- pearances of modification, he allows, that still the eruption was distinctly variolous, and capable of communicating per- fect smalUpox, and that the vaccine vesicle possessed powers of imparting the genuine cow-pox. In addition to the cases I have given in Section III. I have since had several others. The small-pox pustule in one case preceded the vaccine by four days, and the vesicle was about the usual size, was at- tended with a very trifling areola, which co-existed with the variolous areola and fever ; in the other two, the variolous fever and areola commenced on the eighth day, and the vaccine vesicle assumed, on the ninth, an areola about the size of a six-
93
if cow-pox precede small-pox, or small-pox precede cow-pox, the pustule or vesicle of
pence. The fever continued moderate for two days, and nei- ther the areola of the pustule, nor vesicle, became larger ; but on the third day, the fever, from some accidental cause, increased ; the pustular inflammation now extended to the size of a penny.picce, and that of the vesicle became brighter, and was equal in circumference to a farthing. The eruption in the case where the vaccine was four days behind the vario- lous inoculation, only amounted to five dozen, aud a great number obtained the full perfection of a variolous pustule ; in the other two cases, the fever was severe, the eruptions exceeded two hundred, and went through all the stages of complete variolous pustules. From Dr Willan's account of the matter, it is evident, that the vaccine influence is at all events weak, and feeble, in its operation, and cannot con. troul the variolous influence, even although it has preceded it a week, but that the variolous influence is strong and per- feet, and seems to subdue the power of vaccination, altliough co-existing. I cannot admit, from what trials I have made, of the modification of the extent, and appearance of the pus- tular eruption, (which the Doctor seems to consider as a ge- neral rule) if the vaccine and variolous pustules agree in the extent of their progress, or are only from twenty-four to forty -eight hours difference. It appears to me that the im- mediate effects, as well as consequences, are precisely the same as if inoculation had not been accompanied with the vaccine vesicle. I aj)prchcnd the progress of the pustules will be found uniformly to depend upon the number and size of the eruption. Neither can I agree entirely with the Doc-
94
the latest dises^se, will not run its natural course. Dr Adams, on the contrary, states, that they will uniformly do so, and be no otherwise modified, than that the latter ve- sicle, or pustule, will be somewhat smaller. It is not for my present purpose to reconcile these jarring experiments ; it is enough if
tor, that the vaccine vesicle is no otherwise modified but in size, extent of areola^ and rapidity of its progress. From the cases I have met with where vaccination in ^ts progress was a day or two behind inoculation, there seems to be a very sensible approach in the vaccine vesicle to a small-pox pus- , tule ; it not only does not acquire its scab or crust so quick- ly, but even as late as the fourteenth day from vaccination, and the seventh from the formation of the areola, had not ac- quired a complete crust; loses entirely its vesicular appear- ance ; becomes almost completely pustular, and its scab pale, and of a loose, irregular, and soft texture. Were the virus in this state to be used for vaccination, I apprehend that the characteristic vaccine vesicle would not only be found want- ing, but that a very near approach would be made to the va- riolous pustule. At ail events, the whole trials and experi- ments upon this subject, clearly point out the feeble power of vaccination, as an antidote to the variolous influence ; and shew distinctly, that its specific effect is so weak, as to be entirely interrupted, set aside, and destroyed by the vario- lous influencp.
95
we find the subject involved in contradic- tion ; but I must observe, that Mr Bryce seems totally to overlook the effects of the cases contained in his publications upon the subject ; for they certainly distinctly prove, that the small-pox was no way modified, although the cow-pox vesicle and areola previously existed, and that the fever, and eruption of small-pox, could not prevent the cow-pox vesicle assuming its areola, nor even giving its constitutional effect, which must be inferred, according to Mr Bryce's own doctrine, from the appearance of the areola in the double vaccination.
I apprehend it is unnecessary to prose- cute this subject farther ; enough has been said to expose the fallacy of this conclusion, and that we can only explain the whole difficulty, and get rid of the dilemma arising from such opposite experiments, by allow- ing, that the vaccine virus is either totally destitute of that power, necessary to produce
96
a distinct specific constitutional effect, or that it is so weak, and imperfect, as only to exert its influence in a very partial, and tem- porary manner.
CHAP. V.
INQUIRY, HOAV FAB THE PHENOMENA OF TI1£ VACCINE VESICLE WARRANT THE INTRODUC- TION OF THE GREAT VARIETY OF TERMS USED, FOR DENOTING THE EXTENT OF ITS INFLU- BXCE UPON THE SYSTEM.
A particular investigation of this subject seems absolutely necessary for obtaining a fixed opinion of the nature, and powers of vaccination, and also for leading us with pre- cision, to the discussion of that most import- ant question ; what security vaccination af- fords to the constitution, from the influence of variolous contagion ?
Before proceeding to this inquiry, it may be necessary to premise, it is admitted
4J-
r
98
by all, who have had any experience u}Don the subject, that in genera], if) upon the in- troduction of" vaccine virus, a vesicle is pro- duced, characterized, as we have already mentioned, it is found, that such an effect is . produced upon the constitution, that it will resist the effects of variolous virus introdu- ced in the way of inoculation, or exposure to its contagious influence.
In consequence, however, of cases occur- ring, where small-pox have attacked those who were supf)osed to have gone through vaccination, a distinction was found neces- sary^ in order to explain those cases satisfac- torily, and which ended in introducing a variety of terms, endeavouring to convey a more correct idea of the affection.
Most authors, therefore, use the terms perfect, regular, genuine, and constitution- al, in one sense ; meaning to convey, that vaccination has exerted its antivariolous powers upon the system, and that the secu- rity of the individual is perfect, or as much
.99
so as by inoculation. By the terms imper- fect, spurious, irregular, or local, it was meant to convey, that, from some particular ap- pearances in the vesicle, the antivariolous power had been either partially, or not at all imparted to the constitution.
These distinctions, in consequence oflead^ ing to confusion and mistakes, are now pro- posed by Mr Bryce to be done away, and the- two terms of constitutional and local only retained. This, Mr Bryce contends, as both necessary and proper ; those terms, expressive of the appearance of the vesicle, however accurately defined, being liable to doubt and confusion, and as all the variety of vesicles, too, have been found capable of giving the constitutional security. Besides, he apprehends, that a test can be obtained, by which it may be uniformly ascertain- ed, whether or not the vaccine vesicle has exerted its antivariolous powers upon the system ; and therefore, as we are no longer dependant upon the phenomena attending
100
the progress of the vesicle, all its different appearances may be disregarded.
If this was really the fact, much would have been accomplishe'd ; but I apprehend it will appear, that no such test is obtain- ed, and that the other terms to which it has been found necessary to have recourse, are still wanting, not only for characterising the varieties of the vesicle, but also as affording a facility for explaining away, and defeating every objection that can possibly come a- gainst it.
As the vaccinists only contend, that the constitutional, perfect, or complete vaccina- tion, has the power of giving protection from the variolous poison, we must, in our in- quiry, attend to every circumstance, which has been found to influence the production of this state of the disease.
I. — Virus.
Here the author of the practice stated, that the anti variolous effect of vaccination
KING'S CO- 101 ftA£l>lGAL SCHOOL.
might be entirely defeated, by using virus in an improper state.
This assertion was supported, and con- firmed in the most positive manner, by every author who wrote upon the subject ; and it was looked upon as a settled point, in the practice of vaccination, that the most anxi- ous care was necessary in selecting the pro- per period for taking virus ; nay, indeed, so nice and important was this esteemed by its author, that I was credibly informed, he once restricted the period to a few hours. However this may be, it was agreed, upon all hands, that it was absolutely necessary to use the virus in an active, limpid state, ' and that it ought to be taken before the vesicle is surroundecl with an inflamed mar- gin, and not begun to decay ; including, in general, a period between the seventli and ninth day. That, if virus is taken when the vesicle is decaying, or in a state of vis- cidity, it will fail to produce the perfect dis- ease, or, if it should succeed, it will give all
102
the characteristics of the affection on an im- perfect scale, and to a diminished extent.
This opinion is certainly consistent With every fact hitherto known, with regard to the effects of fluids introduced into the sys- tem by inoculation. It is perfectly in uni- son with our former experience in inocula- tion for small-pox, and is also particularly so with regard to vaccination. For who- ever has had but a moderate experience in this practice, would readily find, that, in proportion to his deviating from this rule, his disappointments would increase in the same ratio.
Although it is unnecessary, for the attain- ment of my object, to endeavour to eluci- date this disputed point, yet, as it does show to what an extent the difference of opinion may really extend, and how fbnd the hu- man mind is of invention, I shall bestow a little more attention on the subject.
Mr Bryce claims the merit of dissenting from an universally acknowledged fact, not
103
only with regard to vaccination, but, I will venture to assert, every specific virus what ever. This, too, he does with the full con- viction, of the great delicacy and niceness of distinction, for ascertaining the perfect or constitutional disease, and with a tho- rough sense of the importance of using vi- rus in a limpid state. The substitute he re- commends for limpid virus, is the scab which remains after the disease is finished upwards of ten or twelve days, and which, he says, may be used lor giving the perfect vesicle, many months after.
Independent of all reasoning upon the subject, I must assert, that either Dr Jenner and his followers are all wrong, or that Mr Bryce's substitute is not to be trusted. It is evidently a most palpable contradiction ; and if it is really true that it does give the |:>erfect vesicle, and 'constitutional disease, then all Dr Jenner's, and other authors facts and assertions, must fall to the ground ;
104
that all those important distinctions, and hardly perceptible peculiarities, which are contended for, must be visionary and false \ and the whole phenomena of the disease, must be still overshadowed in mystery, and confusion.
My Bryce asserts, that the scab, or crust, is equally capable of producing the consti- tutional, or perfect disease, with the most active limpid virus ; is one of the best modes for preserving the vaccine virus fit for use, and that it is not liable to the same objections, as when in a viscid and opaque state, He contends, that the hmpid fluid is entirely converted into the semi-transparent hard crust, ^.nd that a pus is formed below it, from the irritation which the scab pro- duces on the raw tender surface, and also, that pus is frequently contained iq the ex- tremity of the circle of the vesicle, at an ad- vanced period of the disease.
It appears to me impossible to conceive,
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by any of the hitherto known laws of the animal economy, or by any knowledge of anatomy, that when a pustule or vesicle changes into the form of a scab, that this scab consists of matter, possessing stronger powers than what it retained when in a state of fluidity, even although somewhat viscid and opaque, and from which fluid, the scab merely follows as the natural con- sequence of acquiring greater solidity, by the processes of absorption and evaporation. It might, perhaps, have been possible to con- ceive, that, had the virus contained in the vesicle been found to acquire additional vi- rulence as it became viscid, that the scab might have been still stronger ; but this is known to be quite otherwise, and, as I have already said, the laws with regard to these fluids are in perfect contradiction to it. It appears to me quite hypothetical to suppose, that the fluid in which the properties of vaccination consists, can, by some unac- countable power of attraction, or locomo-
106
tion, withdraw itself from the extremity of the circle of the pustule, and lodge it- self in the centre, and leave nothing but pus, or inert viscid lymph, in the extremity; and this more especially, when the struc- ture of the vesicle is recollected ; for, as it is alloived to be formed of a number of small cells *, even described by Mr Bryce as resem- bling a honey-comb, an effectual bar must be presented to every such change of situation in the virus, and the virus contained in each cell originally, must remain in the same si- tuation, and undergo all its changes. Be- sides, through all the preceding stages, we have evidence of the centre containing no virus whatever ; for, if you attempt to open the vesicle at this point, you will almost be certain to draw blood, however careful you may be,, showing that, at this point, there is really no vesicle, but a strong vascular con-
* This structure, I believe, was first noticed byDrCappc of York, and has been generally acquiesced in.
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nectionwith the vessels of the surface; and, if 3^ou attempt to -vaccinate with the lancet infected from this part of the vesicle, yon will seldom or never impart the disease. As aproof of this, too, the centre of the scab is the last to be disengaged, the scar being al- ways deepest in the middle ; and these ap- pearances are not merely connected with the vaccine vesicle, but with every pustule and process produced by puncture, which ends in a scab.
As to the description given of the produc- tion of pus, it would appear, that Mr Bryce hardly contends, that tliis appearance is ge- neral' at the latter period of the vesicle, and formation of the scab. If so, it hardly de- serves notice ; because we uniformly find, in all vesicles, that the virus loses its powers in proportion to its period of decay, not depending upon any accidental production of pus, or any other cause. From my own experience, I can assert, that, in all those cases where pus has been particularly produ-
108
ced at this period, it has uniformly proceed- ed firom an injury to the vesicle, by which it was reduced to an ulceration, and, if the scab had not then been completely formed, its appearance also was changed.
But if Mr Bryce means to convey, that pus really forms in every vesicle, towards its conclusion, at the extremity of the circle, then it is evident, there can be no just grounds for the distinction of vesicle and pustule, because it is also only in the advan- ced period of the small-pox inoculated pus- tule, that it assumes this appearance *. I ap- prehend, however, from Mr' Brj^ce's anxie- ty in employing the terms vesicle and pus- tule, he means to convey, not only that there is a material difference in their structure, but also in their contents, and seems anxi- ous to infer, that the vaccine vesicle may
* Dr Jenner and others retain the term pustule, and do not contend for any material difference in the contents of the vac, cine Tcsiclc, and variolous pustule.
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possess very remarkable properties, from its very singular and uncommon organization.
I confess, however, witli the most careful examination by the best glasses, and the most minute attention to the subject, I can see no grounds for this distinction, from the structure, and but very little from the con- tents of the two pustules.
The skin may be safely described as con- sisting of secreting, exhaling, and inhaling tubes, pointing to the surface, surrounded with mucus, nerves, and blood-vessels, over all which, the thin cuticle is expanded, and, upon being examined with good glas- ses, gives the appearance of cells, as it were, sealed hermetically by the cuticle *.
* Although, in a sound state of the skin, perspirable and other matters can be readily discharged through the cuticle, yet, the moment that any cause is applied, capable of pro- ducing irritation and inflammation, it immediately becomes impervious ; and, if the irritating cause is sufficiently power- ful, a vesicle is produced, shewing that the pores of the cu- ticle are so completely obliterated, as even to confine a very thin aqueous fluid.
110
If, upon the introduction of either vac- cine or variolous virus, an inflamed point is produced, this account of the formation of the external part of the skin becomes very evident, and Httle vesicular points are now distinctly perceived, all separated from each other, and as yet forming no distinct vesicle, but gradually extending themselves from the punctured point, to the extremity of the in- flamed spot. In a little time, generally from the third to the fifth dajr, these vesications become large and distinct, and unite into a cluster, forming at last a vesicle or pustule, by being considerably enlarged, and elevated above the rest of the inflamed spot. During the whole of this progress, the point where the lancet was introduced, appears not to be altered in the smallest degree, but remains, as it were, firmly tied down, by the adhesion produced from the puncture, and preserves this appearance through tlie whole progress of the vesicle and pustule. It is tliis cause
Ill
that produces the pit, or depression in the centre ; it is from this point that the pustule or vesicle begins to decay, and, in the ap- pearance of" a crust, gradually extends itself" over the vv^hole. This account applies both to the formation of the vaccine and vario- lous inoculated pustule ; and in no instance have I ever found either of them to xary, unless they had sustained some injury *.
But besides what we have already des- cribed, we shall find, that they also agree in many dther respects. At no period can the virus in either of the vesicles be emptied of its contents by one puncture, and I appre- hend for a very obvious reason, for, indepen- dent of the cellular structure, the centre of
* In some cases of both vesicle and pustule, (but more especially of the pustule,) where they are large, and the in- flammation seyere and extensive, the punctured point seems dissengaged from its situation, and they assume the appear- ailce of a sac or abcess ; but this, too, only at the latter pe- riod of the process.
11^
the pustule, or vesicle, is absolutely oblite^ rated, by its adhesion from the puncture, and the fluid is contained as it were in a ring ; and, upon an opening being made on one side, the fluid in order to be discharged, must necessarily pass through a great por- tion of the circle, which is not to be so rea- dily effected, even were no opposition made from the cells. But I apprehend it is from this very circumstance, that the vaccine vesicle is exposed to the danger of losing all title to possessing the power of exerting any extensive, or permanent mfluence over the system ; for here it expressly agrees with every vesication produced from what- ever cause. It is perfectly well known, that if such vesications are ruptured, they will continue to discharge a much greater quan- tity of limpid fluid than even they con- tained when whole; and the scab, too, that follows such affections, is always dark-col- oured, shining, and hard, if they are allow-
113
ed to o-o thrdudi their natural course. The fact, too, that has been observed of the vac- cine virus losing its activity, after the vesi- cle has discharged a considerable quantit\% shews that its local effects are so weak, and partial, as not to impart a sufficient strength of organization, capable of preserving its spe- cific qualit3^
I am of opinion, that those who made the account of the two pustules to differ so considerably, drew their conclusions, from comparing the vaccine vesicle, with the variolous pustule, produced by eruption. There the description is nearly correct, but certainly the conclusion is not warranted ; for there can be no affinity in appearance, between a pustule produced from virus in- troduced on the point of an instrument, and one following an eruptive fever.
But if any doubts still remahi, they ap- pear to me to be entirely settled, by what we observe take place in thoge pustules
H
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produced by eruption; for the circumfe- rence exactly resembles the appearance al- ready described to exist, of that from ino- culation, with the centre at first depressed, but which gradually rises, and assumes a more prominent appearance than the cir- cumference, and seems distinctly to re- semble a bag containing fluid. Also, upon laying open the pustule, the cavity only corresponds with the extent of the centre, and 'does not extend to the margin, or that portion of the pustule which first existed. We may besides observe, that the cellular - appearance seems clearly to depend upon the extent of the inflammation ; for we find that, in those secondary vesicles, which sometimes attend vaccination, they are far from being distinct, and approach nearly in appearance to the small-pox pustular erup- tion ; for there, no central crusts are to be found, the whole fluid may be readily dis- charged by one puncture, and, upon remov-
ii5
ing the surface of the vesicle, a distinct ca- vity is found to exist.
As to their contents, there really exists, in this respect, but little cause for the intro- duction of a new term. The fluid contain- ed in each has the most exact resemblance, until the ninth, or tenth day, being limpid and fluid ; they soon after become gradu- ally viscid, and opaque,, and not only as- sume the appearance, but actually have become pustular. The only difference to be remarked is, that the inoculated pustule more distinctly assumes the appearance of perfect pus, is larger and more unequal in its figure; its extremity irregular, and jagged; its period of decay more protracted ; and the scab, or crust, in general of a paler colour. We may, however, remark, that very fre- quently the severe cases ot" the one, and the mild cases of the other, so nearly approach, in every respect, as hardly to be distinguish-
ed by the most experienced inoculator * ; from which it would appear, that the great- er resemblance of pus, entirely depends up- on the extent of the inflammation, as it is well known, that it is always much more severe, and extensive in inoculation, than in vaccination.
While I am thus so strongly confirmed in ray opinion, of the scab being deficient in point of" activity, I am far from assert- ing, that it possesses no power. Besides the ample testimony given by Mr Bryce> and other practitioners, I am also convinced, from my own experience, that it is capable of producing the regular vesicle, and per- fect disease, but farther than this I cannot go. We might with equal justice assert, that the crust of small-pox is equally pro-
* Indeed, in almost every case, the pustule and vesicle re- temblc each other so strongly during the first six or seven days of their progress, that, although existing on the same arm, at the same time, they cannot be distinguished from each, other.
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per for inoculation, with the hmpid virus ; because we all know perfectly, that it retains a sufficient quantity of the variolous con- tagion for communicating the disease. I have no hesitation in asserting, that the same deficiency of strength, and activity, will be found to attend the vaccine scab, and that it Avill very frequently fail, unless the mode of introduction is much more se- vere ; it will also only produce a vesicle, slow in its progress, smaller in its size, and with a very small, and feeble ring-like in- flammation. ■ Upon the whole, I think we are warranted to conclude, that, if the vac- cine scab, or crust, really possesses the power of imparting the complete effect of vaccina- tion to the system, to the same extent with the limpid virus, it is not only in direct cour tradiction to general experience, and analor gy, but also clearly evinces the imperfection, and incpnsistency of the whole subject.
US
' II. — Vesicle.
It does not appear necessary to take up pur attention, with any of the appearances pf the puncture, previous to its having as- sumed the form of a vesicle, as they do not afford the smallest foundation for ascertain- ing, or characterizing the disease. But when it has gained the state of a vesicle, pr pustule, it is supposed not only to be characteristic of the affection, but also to afford a distinct proof of the perfection of the process of vaccination.
We have already stated the description of the process of the punctured point, as it appears to us, and have also given an ac- count of it, as described by Dr Jenner and others; but notwithstanding the minute- ness, and accuracy, of these descriptions, and the seeming uniformity, and regularity, with which they are said to follow the in- troduction of the vaccine virus, yet it is on this very point, the most remarkable varie-
U9
ty, and confusion exists ; some contending for the vesicle assuming, upon every occa- sion, the appearance already noticed, as cha- racterizing a constitutional, or perfect ve- sicle ; others that this is not necessary ; that every variation of size, figure, and co- lour is not material, if only a vesicle is formed, short of suppuration, or a pustular appearance.
It is well known, that, upon the intro- duction of the practice by Dr Jenner, the size of the vesicle was understood to be considerable ; in most cases at least equal to the size of a seven shilling piece, the figure circular, with an edge somewhat ir- regular, and more elevated than its centre, and its colour distantly approaching to blue. It now appears, there is not one of these peculiarities but what may be dispensed with. The size may not exceed a ^ht pea, the characteristic figure may be nearlj^- if not entirely lost, and without the least shade
ISO"
of blue, and still the antivariolous power as complete, as from the most perfect, and ap- proved form, and capable of resisting the tests of inoculation, revaccination, and ex- posure to the epidemic.
If we were formerly surprised with the incongruity of the opinion, that the scab, and limpid virus, are equally effectual and pro- per, what must we think, if, besides what has been just now stated being proved from ex- perience, it is also asserted, that there are im- perfect, or spurious vesicles, confessedly ow- ing to no purulent matter, and that these vesicles are capable, vice mrsa^ of giving the imperfect, or perfect vesicle ; and farther, that even these avowedly imperfect vesicles, still resist all the common tests. But to put this part of our subject in the most conspicuous form of absurdity, and contra- diction, we shall just quote a passage in the Appendix to Mr Bryce's last publication. He observes, " Although I have said that
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what has been called the spurious cow-pox, and the irregular vesicles, are only local af- fections, I am well aware that they are of- ten attended with fever, and other symp- toms of constitutional excitement ; but I am clearly of opinion, that these symptoms •of constitutional excitement, are not the ef- fect of the inoculation, but of some mor- bid action in the constitution, inimical to vaccination, and that this constitutional ex- citement is the cause, and not the effect, as has been imagined, of the irregularity ob- served in the progress of the affection at thq part inoculated." : ^^-^
As this subject will fall to be considered in another place, we shall only just observe, that this perhaps might be all very true ; but how comes it, that, if such cases were either to be submitted to inoculation with variolous virus, or to be exposed to the epi- demic disease, they would be found iini' for mil/ to resist these tests ?
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Dr Willan, too, observes, " The effect of vaccination, when there are irregular ve- sicles, is different in different cases. They appear fully to secure some individuals from the infection of small-pox ; in others the constitution is but imperfectly guarded against the small-pox by those vesicles, the disease taking place after them at different intervals, under a particular form." Again, " Imperfect vaccination is not characterized by any uniform sign or criterion, but exlii- bits, in different cases, very different appear ances, as pustules, ulcerations, or vesicles of an irregular form. I have observed three sorts of" irregular vesicles. The first is a single pearl-coloured vesicle, set on a hard dark-red base, slightly elevated. The se- cond appears to be cellular, like the genuine vesicle, but is somewhat smaller, and more sessile, and has a sharp angulated edge. The third is a vesicle without an areola."
According to Dr Woodville, " Whenever
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vaccine inoculation excites a pustule (ve- sicle) of any kind, though it continue but for one or two days, and should be succeeded by an ulcer, the inoculation is as effectual as where the vaccine tumor has proceeded in the regular manner."
It is absolute folly to pursue this part of our subject farther; suffice it to say, that the vesicle is admitted, by all who have had any experience, to be a very uncertain cri- terion of the perfect disease, and that the variety of the vesicles do not, from their effects, warrant the introduction of those terms, used for denoting the extent of their constitutional influence.
III. — Areola.
The next phenomenon which is found to attend the progress of the vaccine ve- sicle, was supposed to form one of the most characteristic, and decisive tests of the ex- istence, and completion, of the process of
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vaccination. When the vaccine vesicle has arrived at the eighth or ninth day, an erysipelatous inflammation begins to appear round the base of the vesicle, and this <rra- dually increases to a , greater or less extent. That portion of the inflammation which is near the vesicle, is in general of a deep red, swelled and hard, but as it extends, be- comes faint, and then again, at its termina- tion, becomes a shade or two darker. The termination of the first appearance, gives what is called the single areola, and the termination of the whole erysipelatous ap- pearance, gives the second, or double areo- la. Every practitioner who has had any ex- perience in this disease must, however, have observed, that this double areola is not even a general phenomenon, far less uni- versal, and that the most common appear r ance is a mere circular inflammation ; that the extent of the inflamed single or double areola, varies from the diameter of two in-
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ches to that of a sixpence ; that although the erysipelatous inflammation is present to a great extent, still you may have no regular areola of any kind ; sometimes it is jagged, and irregular ; sometimes hard, and considerably swelled ; and very fre- quently neither of these takes place.
Dr Willan thus describes the areola which attends the perfect vaccine vesicle : " The areola which is formed round the vesicle is of an intense red colour ; its duration differs in different persons, from a quarter of an inch to two inches, and is usually attended with a considerable tumor and hardness of the adjoining cellular membrane." In the irregular, or imperfect vesicles, (which, it must be recollected, he allows are capable of protecting the constitution against vario- lous contagion, to a certain extent), he says, " That the areola of the first sort is usually diffuse, and of a dark rose colour ; in the second, it is sumetiiiies of a dilute scarlet co-
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lour, radiated, and very extensive, as from the sting of a wasp ; at oihe?- times (it is of a very trifling extent and pale colour), as exhibited in (his) Plate I. No. 7." The are- ola, the Doctor adds, appears round the im- perfect vesicles on the seventh or eighth day from vaccination, and continues for three days, more or less vivid ; he does not mention the day that the areola of the per- fect vesicle appears, but, from observing that it begins to decay about the eleventh day, we must infer that it also makes its appear- ance about the eighth day.
The double areola, or any inflamed ap- pearance whatever that attends this affec- tion, has been supposed to be of a singular appearance, and characteristic alone of vac- cine virus. From experiment, and the most attentive observation, I am convinced, that incidental circumstances have a great share in producing the whole of this pecu- liarity, and variety. The modes of per-
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forming the operation by which the virus is introduced are various. If you use the mode by puncture, or a shght scratch, you will generally have a vesicle, going through its stages steadily, but not rapidly, and at- tended with a double areola ; but if you do it by incision, a deep puncture, or seve- ral severe scratches, and at the same time using very active limpid virus, you will have a vesicle, not answering exactly the characteristic description, going through its stages more rapidly, the centre assuming a. more elevated appearance, accompanied with an inflammation, giving at best only the single areola, but often not regular, al- ways of a deeper red, jagged in its circum- ference, and generally attended with swel- linsr, and hardness. Besides the influence of the different modes of introducing the virus, external circumstances have their ef- fect ; if the vesicle is frequently pressed, rubbed, or kept hot, from the child lying
ns
too much upon it, it will also contribute to increase the inflammation.
In addition to these causes we know, that, in inoculation, the symptoms of inflamma- tion in general run high, and you seldom observe a regular ring-like appearance ; but if they should happen to be moderate, it makes so very near an approach to the ap- pearance of vaccination, that Dr Jenner hailed the similaritj^, as the surest omen of his success. Dr Adams, too, in his experiments shewing the identity of the vaccine and variolous virus, clearly proves, that the areola is in a great measure re- gulated by the severity of the inflamma- tion ; for wherever a mild case of small-pox inoculation was produced, it made a near approach to the appearance of the vaccine vesicle, and areola.
That such accidental causes are the prin- cipal, if not the whole source of the peculia- rities observable in the areola, is further
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corroborated, by the appearance which is found to take place in double vaccination ; for there, the single, or double areola, is uniformlj^ distinct, but only in miniature.
We also find, that in proportion to the severity of the inflammation, a pustule, or tumor of any description, will depart more or less from a regular circle.
Whatever may be the nature of this phenomenon, or the cause of its varieties, we are still, however, positive as to one material fact, that the same antivariolous power is imparted by all the different ap- pearances, and that no countenance is af- forded for the introduction of such a va- riety of distinctions, from the actual result of the practice; for, according to every author, the areola may be either present in whole, or in part, nay even absent, and still the vaccination of the system accom- plished, so as to resist every test that can be then applied.
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IV. — Constitutional Si/j?iptoms. If we are disappointed in obtaining satis- factory information from the circular inflam- mation round the vesicle, we shall receive ibut little additional comfort from the con- stitutional symptoms. At first sight, it would naturally be concluded, that if, together with the appearance of the vesicle already de- scribed, any constitutional affection, such as swellings in the arm-pit, fever, sickness and startings should occur, that the vaccine ino- culation had gone to the utmost extent of its powers, and that it not only ought to be a certain criterion, whereby to judge of its having exerted its influence upon the system, but also, that this influence was complete. But unfortunately we are still in the same confusion, and contradiction, as from any other phenomena we have already examined. The most perfect form of vesicle, and areola, geherally produces no such symptoms, and still the antivariolous power is exerted; again.
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aW the varieties of the vesicle, and areola, are found to have produced constitutional effects, followed with the same antivariolous power.
Dr .Tenner, unhappily, on his introducing the discovery to public notice, made an as- sertion which, in my opinion, struck at its root in the most violent manner. He ob- served, that the constitutional symptoms which took place, either in casual, or inten- tional vaccination, were not owing to the exertion of any influence over the system, but merely to the local irritation arising from the inflamed vesicle. In consequence, however, of the occurrence of many cases, quite irreconcilable with this opinion, and sensible, I dare say, of the error he had com- mitted, he found it necessary to admit the existence of a constitutional affection. From the same necessity, he was also obliged to go a step farther, and request the additional indulgence, that although it was found from experience, that a person might have the
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same constitutional sj^mptoms, arising from vaccination, repeatedly, none but the first were constitutional, and that all the suc- cessive attacks proceeded entirely from local iri'itation.
Although I have no hesitation in allowing, both the necessity, and the reality of a con- stitutional influence being exerted, in order to produce whatever effect it is capable of, yet still, if such concessions are to be made, and such palpable contradictions overlook- ed, it may be safely asserted, that such encouragement was never before afforded to any innovation, and that all the rules of evidence are winked at and neglected, mere- ly in deference to the support it receives, from one, or two, material facts.
We must first observe, that there is no oc- casion for making any distinction betwixt the effects produced upon the system by ca- sual, and intentional vaccination; as it is universally allowed by all who have either
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wrote upon the subject, or had experience in this practice, that the security afforded is the same, and also, it is proved to be as complete from the vesicle, whether it produces symp- toms of constitutional affection, or not*.
I do not take it upon me to say, that these opinions are correct, but that such are the result of experience ; and, notwithstanding it is acknowledged, that such is the fact, yet still Dr Jenner, and now all vaccinists contend, a constitutional influence must take
* Dr Jenner says, " Those persons on whom the vaccine vesicle has been excited by perfect matter, and has complete- ly gone through the progressive stages of inllammation, ma- turation, and scabbing, are ever after secure from the infec- tion of small-pox." In the year 1806, the Doctor, in a let- ter to Dr Willan, observes, that " Vaccination gives com- plete security to the constitution, when no indisposition has been perceptible throughout the whole progress of the pus- tulcs (vesicles) on the arms. I once had some doubts on this point, but i am now, and have been for many years past, perfectly convinced they wore groundless." Dr Willan also says, " During the progress of the vesicle, some symptoms of disorder take place in the constitution, but they do not al- ways occur, nor are they deemed requisite to insure the full effect of vaccination."
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place, in order that the individual who sub- mits to the practice, should be put in a state of perfect security.
The dilemma, therefore, appears to be, not that constitutional symptoms must be ob- tained, to render it capable of giving securi- ty, but that, as such security is given from the other phenomena of the affection, how are we to come at the knowledge of its hav- ing taken place ?
V. — Tests of Const! hit ional Vaccination.
We have already seen, that it cannot be from the leading phenomena of the disease itself ; accordingly, revaccination, inocula- tion, and exposure to the effects of the vari- olous contagion were had recourse to. From the first test, nothing was produced but doubt and uncertainty^ and considerable danger was even incurred, of bringing the practice into contempt. From the others, the whole props of the discovery were oh-
135
tained, and the greatest satisfaction univer- sally imparted. The result of these proofs were, that they uniformly resisted inocula- tion, and the contagion of variola could ex- ert no effect upon them.
As we shall have occasion to resume these points in another place, I shall only at pre- sent observe, that these tests wfere at the in- troduction of the affection found, almost uniformly, to follow from every vaccination, where a vesicle was produced, with more or less of the characteristic appearances de- scribed by Dr Jenner, and deemed a suffi- cient proof) not only of its having exerted its constitutional influence, but that this in- fluence was complete. This point seemed to be entirely put to rest, by the immense volume of evidence brought forward ; and the characteristic phenomena of the disease were so well understood, as to supersede every other trial. A few years, however, had scarcely elapsed, before cases occurred.
136
which rendered it necessary to investigate the subject more closely; it was found requi" site to throw considerable doubts upon the phenomena of the disease, and that nothing short of a distinct constitutional influence would afford perfect security. To recur to any of" those tests already practised, would certainly appear absurd, and, if used at the same period after vaccination, could afford no better proof
In this state of things, an expedient was prop(^ed by Mr Bryce, which should effec- tually banish, not only all doubt about the constitutional influence having taken place, but also, that it was exerted to the extent necessary for imparting, the required secu- rity against variolous contagion *,
* Mr Pearson, surgeon to the Lock Hospital and to the Public Dispensary, mentions, in a letter to Dr Willan, that
In the early part of the year 1801, I ascertained, that if a second inoculation with vaccine fluid be performed on the sixth or seventh day, a pustule (vesicle) will arise, which pro- ceeds in the usual manner, until the efflorescence appears
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Mr Bryce revived, and applied for this purpose, a well known fact in inoculation ; that if you puncture the skin with a lancet infected with the same virus, some days after the first inoculation, if the first pro- duces the disease, the others will rapidly advance, and gain the same maturity as the first, only in every respect less extensive. In repeating this experiment with the vac- cine virus, the same result follows ; and a ve- sicle is produced, having all the characteris- tics of the original puncture, but only on a much smaller scale. This phenomenon, Mr Bryce contends, is a certain, nay indeed
round the pustule (vesicle), produced by the first inocula. tion ; and that, as soon as this takes place, the second pus- tule (vesicle) begins to fade, and two or three days afterwards disappears altogether. On mentioning this as a test of the specific action of the vaccine fluid, it was suggested, that a proposal of this kind might diminish the public confidence in the new inoculation, in which T acquiesced, but the fact may, however, be worthy of record." This description of Mr Pearson's double vaccinations does not at all correspond with Mr Bryce'Sj and seems directly to militate against them.
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the only criterion of ascertaining, that vac- cinnation has exerted its influence complete- ly upon the constitution.
If double vaccination reallj'- exclusively possessed this proper t}^ it ought to be cer- tainly universally practised, but I am afraid^ ' upon examination, it will be found to have no better pretensions, than can be afforded from the phenomena we have already ex- amined.
Independent of every other consideration, it is to be observed, that such a proposal carries, upon the face of it, that some doubts hang upon the practice ; and besides, this second, or even treble vaccination, is not a proof that will be always submitted to by the parents. But it is also to be particular- ly remarked, that as the secondary vaccina- tion may fail, and the firstvesicie go through the regular course, you deprive the parent of complete satisfaction ; for it is contended by Dr Jenner, that it is not possible to pro-
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ducc another constitutional vesicle, and of course, you cannot afterwards procure the test required, although you should suhmit to re])eated vaccinations.
Besides, it appears from Mr Bryce's cases, that, unless the secondary vesicle has been sufficiently advanced, it cannot be made to assume the appearance of the regular vesi- cle, or areola, even although the primary one has not yet previously acquired its are- ola, and not even after it has taken place, although accompanied with constitutional symptoms.
But larther, from the examination which has already taken place, of the proofs afford- ed from the vaccine })henomena, of the an- ti variolous process having been effected, it would appear, that all the phenomena of the regular vesicle, and constitutional symp- toms, may occur repeatedly in the same per- son : that even in the primary vesicle, this may be obtained, without the existence of
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the areola, upon which so much stress is laid, even in the secondary vesicle ; and surely Mr Bryce cannot say, that he is able to obtain from the secondary vaccination an areola, if it does not exist in the primary. But again, from the cases brought forward by Mr Bryce, it would appear, that this areo- la, attending the secondary vesicle, may ex- ist without the smallest evidence of any con- stitutional symptoms. Also, in all those cases, which according to Willan, Ring, Bell, and almost every other writer, are de- nominated, irregular, and imperfect, it will be found, that the vesicle and areola will be rapidly produced in the double vaccination, if the vesicles are only accompained with an areola of any kind *.
• Dr Willan observes, " That this test of double vaccina- tion will fail, if the fluid employed for the second puncture be taken from the person's own arm, when the vesicle is one of the irregular kind, which produces disorder of the consti- tution, but affords only an imperfect security against small- pox." We cannot resist this opportunity, of putting the
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We shall afterwards find, that Mr Bryce will not allow of a weak or modified action of the antivariolous powers of vaccination, but contends, that if it does exert a consti- tutional effect, it must, in every instance, be perfect and complete. Dr Willan, as well as many others we have seen, grant, on the con- trary, that certain states, and appearances of the vaccine vesicle, give only an imperfect se- curity, and allow of a recurrence of small-pox. Mr Bryce, therefore, having obtained the test of double vaccination from all appear- ances of vesicles and areola, must either give up this favourite improvement, or main- tain that these vesicles are all perfect, and the constitutional influence imparted. On the other hand, Dr Willan, not being able to deny the test of double vaccination, and
attempts to reconcile the most opposite facts, aud opinions, in the most conspicuous point of view, and to show, that the abettors of the practice are more anxious to preserve con- sistency, than to elucidate the subject.
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having already distinctly allowed an imper- fect, or incomplete antivariolous influence, must either give up such an opinion entire- ly, and, along with it, a powerful, and ready excuse for every failure, or fmd out an ex- pedient for reconciling two such opposite assertions ; accordingly, at page 79, he gives the paragraph we have already noted, and seems willing to meet Mr Bryce half waj^ Mr Bryce, however, does not seem inclined to accept of the compromise, and requests to know, whether this declaration of the Doctor's, he merely a consequence of the ihcory which he has formed regarding the constitutional action of irregular vesicles, or as a fact founded upon the Doctor's own experience ? From the opinion I entertain of Dr Willan's discretion and judgment, I apprehend it is a question he will not at- tempt to answer ; and I am afraid it is a request which Mr Bryce would have done well to have avoided, if he was anxious for
143
maintaining the character of vaccination in any decent state of consistency.
But there is a curious circumstance, stated by Mr Bryce, as having been ob- served by Mr Gillespie, which, if it was to be taken as a general appearance, in such circumstances, would not only throw a far- ther obscurity upon this test, but also go a great way to shake the whole history of the disease. He says, that a child was vaccinated, as usual, in the double form, but, previous to the existence of an areola, in either of them, the child sickened for two days, and an eruption of small-pox follow- ed. After the sicknef6 and fever went off, both the vesicles became inflamed, and had each an areola at the same time. It is only necessary for our present purpose to ob- serve, of this case, that, in those secondary areolae, formerly alluded to by Mr Bryce, they did not exist at the same instant with the primary one, but followed at the dis- tance, at least of twenty-four, or thirty-six
144
hours; here, however, although kept in their previous state by the variolous fever, they both assumed the areola together.
Mr Bryce also mentions another circum- stance, which appears to me to throw no small doubt upon the accuracy of this sub- ject ; for I apprehend it is quite contrary to all experience, at least I can safely say, it is in direct contradiction to mine ; he says, that if any accidental cause should occur, capable of exciting fever, or disor- dering the system, such as teething, that the progress of both vesicles will be inter- rupted. Now, I apprehend, it will be found both in vaccination, and inoculation, that if feverish heat is excited by any cause, not capable of producing a distinct specific in- fluence, it Avill unavoidably quicken the progress of both vesicles, and pustules*.
* This cause is neither noted by Drs Jenner nor Willan, as preventing the regular progress of the vaccine vesicle, and it is observed by other practitioners, that the disease may be satisfactorily obtained during dentition.
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If we consult analogy, too, upon this point, we shall find, that if the body labour under any feverish paroxysm, even in cases of the attack of any of the exanthemata, should there happen to be at the time any wound, scratch, or puncture, it will instantly in- flame, and acquire an areola, more or less distinct, in proportion to the nature, figure, and size of the part affected ; or if you puncture, or otherwise wound any part of the bod}^ while in a feverish state, from any accidental cause, there will be pro- duced, in a short time, even within a few hours, an inflamed painful tumor. If, while the system, too, is deranged from the effects of an accidental tumor, whether necessarily ending in suppuration or not, if you wound any part of the surface, it will frequently produce an inflamed appearance, directly. I have also often observed, in certain states of the constitution, where a hard, and se- vere inflamed tumor took place, that it was^
K
146
frequently followed by a number of others, all arriving more rapidly at their height.
I apprehend, from an attentive review of these, and every other fact connected with vaccination, it will distinctly appear, that, as this test can be obtained in a variety of circumstances, where it has never been supposed that any specific con- stitutional influence was exerted, it cannot be depended upon, as indicating any action of the system, by which it may be inferred that an active, or permanent influence, has been imparted. At all events, it cannot be considered as better, than what can be ob- tained from the characteristic phenomena of the vaccine vesicle itself, and is not entit- led to more attention, than where the areo- la exists in the primary vesicle ; for, as I have already observed, I apprehend even Mr Bryce will hardly affirm, that he has ever seen the secondary areola, without its having
147
previously existed in the primary *. If this ' is the fact, which I presume it to be, both from what is stated by Mr Bryce, and from my own experience, we have an equally certain criterion, without this additional trouble, and without, too, throwing any doubt, or stigma upon the disease.
What then is to be done ? are we to have re^ course to revacci nation, or inoculation, some weeks or months aftervvards? From what has been already noticed, it appeared, that the vaccine vesicle can be produced over, and over again, and even is allowed by Dr Jenner
* We may here, too, observe, that in all those cases, where vaccination and inoculation have coexisted, and where the vaccine vesicle had not acquired its areola previous to the existence of fever, and the small-pox areola, that the vaccine vesicle immediately obtained its areola, after the areola fron^ the inoculation, and afterwards exadtly corresponded, in du- ration and extent, with tlie variolous ; from which it would appear, that the specific variolous action quickens the pro^ gross of the vaccine, and that the areola of the cow-pox ve- sicle is merely indicative of its local influence, and is subject to the same laws witH any other pustule, or tumor, that may accidentally exist, while the system is under any feverish iii- flueuce.
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to be attended with constitutional symptoms repeatedly. My experience on this point enables me to say, that if you Tevaccinate some weeks or months, after having in the first instance produced a vesicle properly characterized, I have seldom or never been able to produce it again ; but if you delay it for a year or two, you will readily succeed in producing the perfect vesicle. I must, however, confess, I have never seen it, in any of those instances which I have hither- to met with, attended with a large and dis- tinct areola. I have, however, never vac- cinated any after this period ; and it appears to me highly probable, that if it was delay- ed some years longer, all the other appear- ances might be regularly obtained, as we find Dr Jenner allows, that, in many cases where vaccination was reproduced casually, all the phenomena of the disease were pre- sent.
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From these circumstances, then, I appre- hend it cannot be contended, that this is deserving of any attention ; inoculation is the only thing we can fly to ; it gives neither- more trouble, nor pain in the ope- ration, and if the virus succeeds in produ- cing an inflamed point, which afterwards arrives, in from five, to seven or eight days, at an inflamed tumor, it is an equally strong proof of the variolous virus having exerted its local influence. Besides, it would have produced the variolous disease in its usual form, had it not been anticipat- ed by the effect of the vaccine virus on the system, and therefore it affords, not only the test, that the previous vaccination had been constitutional, but also, that it really resists the effects of the variolous influence, from which all concerned will derive greater confidence, and satisfaction. I apprehend, from the whole of what we have now said, it will clearly appear, that, notwithstanding
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all the variety of the vaccine phenomena, still the antivariolous effects are exactly the same ; that what has been called the tests of constitutional vaccination heaving been imparted, are no better than what can be obtained from the characters of the disease itself; that there really exists no founda- tion whatever, for the introduction of those numerous and intricate distinctions, as con- veying a more correct idea of its extent, and efficacy; and that they only afford a very great facility for evading the force of every objection, or fact, that can possibly l)e brought against the practice.
CHAP. VI.
CASES.
Sect. I.
Cases of Small-pox succeeding to Vaccination. Cases I, II, III, and IV.— June 1808.
In the month of June last, I was desired to visit the child of a very respectable but- cher in this place, about three years old. T found it covered over with an erup- tion, attended with considerable fever, which, the mother said, had much abated since it made its appearance. The erup- tion had then only been out two days, it had not the appearance of chicken-pox, and wanted some ot the characteristics of
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small-pox, such as the depression or pit in the centre, had Httle or no inflammation round the base of the pustule, and were prominent and small. The child having been vaccinated by myself, in the most perfect form, both from my own recollec- tion, and from what I had expressed to the mother, I inclined to give my opi- nion, that it was not the small-pox. The pustules, were about two, or three hun- dred in number, and decayed about the fifth day. Upon farther inquiry, I found the small-pox were epidemic almost next door, and that several children were then ill of that disease. The opinion I had given was soon overturned, and I was un- der the disagreeable necessity of acknow- ledging it to have been a case of small-pox, for, in about eight days after, another of the $ame family, about six years old, became sick ; in a few days a copious eruption made its appearance, which, upon a mode-
153
rate computation, might exceed a thousand pustules. In this case, the disease went through its most regular form, the pustules did not decay until the 7th or 8th day, and the blains upon the face did not disappear for many weeks. In a few days more, a a 2-irl about five years old became sick, and went through the disease, nearly in the same form as the last ; and a fourth, about lour years, was so sick, as to keep his bed for several days, but no eruption made its appearance, although there was a rash for about twenty-four hours. There was ano- ther child in the family, about ten months old, but no effect was produced upon it The whole five had been vaccinated by me when about the age of three or four months; they had the disease according to my own recollection, and also from my opinion ex- pressed to the mother at the different pe- riods, in the most perfect form ; and lancets >vere infected from all of them. The cica-
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trices are all large and distinct. The fa- mily consisted of other two children, who had been inoculated, but had not the smal- lest complaint.
Gases V. and VI.— July 1808.
In the beginning of July last, having heard that one Gibson, a fisher in Mussel- burgh, had a child affected with small-pox, after having been vaccinated, I called, and found his son John, aged three years, with maturated pustules, to the extent of five or six hundred. It was then about the eighth day, and they were just begun to decay. He sickened a day after a younger brother, aged sixteen months, who died of the disease, but was not vaccinated. John had been four times vaccinated about six months old, until it succeeded, by practitioners in this place, and the fourth time was followed with a perfect pustule, and the most regu- lar form of the disease, according to the
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opinion of the medical attendant. The mo- ther still describes the vesicle to have been large, the inflammation equal in circumfe- rence to a penny-piece, and the cicatrix is still very large. The small-pox were epi- demic all round, and no chicken-pox heard of at the time. Henry Gibson, of the same family, now aged seven years, was vaccinated when about five months, and it was again repeated when seven, in consequence of its failing, and, although done in two places, the pustules were so small, and the inflam- mation so trifling, as to make the practi- tioner in attendance suspect, that he had not undergone the perfect form- of the dis- ease. There are, however, two distinct, though small cicatrices upon the arm. When about three years old he sickened, and had so copious an eruption of smalls pox, as even now, at the distance of four years, to be much pitted ; he was infecte(^
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from an older brother, who died of the dis- ease.
Case VII.— July 1808.
George L Musselburgh, about se- ven years of age, was vaccinated b}'^ Mr Stewart, surgeon in Kelso, when some months old, who expressed himself perfect- ly satisfied of its being the genuine form of the disease ; and, from the appearance that the mother describes the vesicle to have assumed, and its corresponding with that of her other two children vaccinated since that period, together with the usual ci- catrix, there can be no doubt of his having undergone vaccination in its usual and proper form. He was attending school when he sickened, about the end of July, and after three days of excessive sickness, attended with ' strong symptoms of exan- themata, an eruption made its appearance, to the extent of at least two hundred pus-
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tules, which continued to maturate until about the sixth day, and then rapidly decay- ed *. He was attending school ; the small- pox were epidemic in the neighbourhood; and no other eruptive disease was then known. The other two children, both younger than himself, did not complain in the smallest degree. Thei-e were several
* The following description will answer for the whole of those cases, where the pustules decayed by the fifth or sixth day. During the first three days, they had all the characters of a perfect small-pox pustule ; were hard, globular, and inflamed, gave a distinct round feeling under the finger ; in most of the cases, the pit, or depression in the centre, was evident, but in others, where the eruption was smaller, the depression was wanting. Upon no occasion was there the smallest watery vesication, like chicken-pox, and no matter was formed before the third or fourth day. Upon all occa- sions, where the eruption exceeded some dozens, they became less or more pustular, and always a certain number upon the face and trunk of the. body, were distinctly so. After gaining this state, they then rapidly decayed, and scabbed ; the scab was uniformly round, generally hard, and dried off, in the most characteristic form of small-pox, but more quick- ly. In those cases where the number did not exceed a dozea or two, they never became pustular, but remained hard, redj and papular, and decayed without leaving a scab.
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more children in the family, all older, who had undergone inoculation, but none of them complained, or had any eruption.
Case VIII.— July 1808.
Hugh Peacock, Musselburgh, now si5c years old, was vaccinated by me, when about three months. From my own me- mory, the mother's report of the appear- ance of the arm, lancets having been in- fected by me, and also by another practi- tioner in Mussleburgh, (who was attracted }>y the very beautiful appearance of the vesicle and areola), and from the appear- ance of the scar, I have no doubt of his having undergone perfect vaccination. He sickened in the end of July, which conti- nued severely i'ov three days, attended Avith delirium, and great appearance of convul- sions. These were succeeded with an erup- tion of from two, to three hundred pustules, which did not arrive at complete maturO:-
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tion until the seventh or eighth day. The small-pox were prevalent all round, and two or three had died in the immediate vi- cinity. He did not attend school, but went about the streets with his companions. He had a sister in the house, who was then aged three years, that had been also vac- cinated by me ; she had not the smallest complaint. There were other four children in the familj^ who had been inoculated, but they had no complaint whatever.
Case IX.— July 1808.
Walter Ritchie, Musselburgh, about five years and a half old, was vaccinated by me when about the age of five months. He went through the disease, in my opinion, expressed at the time, in the most perfect form. The mother remembers the ve- sicle to have been much inflamed ; the scar is still quite distinct, and several children were vaccinated from him. He was at-
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tending school, where many had taken the natural small-pox, and, about the end of July, sickened ; he continued so for three days, when an eruption followed, to the amount of two or three hundred pustules, and arrived at maturation in about the fifth, or sixth day, and then rapidly decay- ed. There were other three children in the family, all younger than himself, who had been all vaccinated successively, about three or four months old. None of them were in the least affected. There was no eruptive complaint of any other kind, epi- demic at the time.
Case X.— July 1808.
I was requested to visit a son of Mrs Stirling's, midwife in Musselburgh; he was about nine years and a half old, and was then confined to bed with every symptom of a smart fever, which, after continuing two or three days, was followed with an
f6l
eruption, to the extent of four, or five do- zen of pustules, which continued to increase until about the fifth or sixth da}^ and then decayed. The small-pox were epidemic in the neighbourhood, and he attended school, where a considerable number had been affected with the natural small-pox, and some had died. No chicken-pox, or other exanthemata, existed at that time. He had been vaccinated, when a year and a half old, by the late Mr Corbet, surgeon in Falkirk, who, as well as another practition- er in the same place, that saw the arm, were quite satisfied of its being the most perfect form of vaccination, and both infected lan- cets fi-om the pustule. The mother says the arm was very much inflamed, and the cicatrix is still very large. Th6 family con- sisted of other three, older than himself) who had been all inoculated, but had not the smallest complaint.
m
Cases XI. and XII.— June, iSOg.
Hearing that John Baux, a labourer in East Duddingston, had four children affect- ed with natural small-pox, and that two of them had been vaccinated, I determined to call and inquire into the fact. I found them all four evidently labouring under that dis- ease, in^ different stages. The two that had been vaccinated were a boy and girl, the oldest seven and the other five; the girl had been vaccinated by Mr Newbigging about nine months old, and the boy by a -practitioner in Musselburgh when about seven. From the report of the mother, they were both satisfied at the time, and lancets were infected from one, if not both. The girl was vaccinated with the same virus, which Mr Newbigging used for infecting another child, and at the same period, as the mother of the girl was nurse to the child. The scars from the vaccinations are
163
also very distinct. The eruption upon both exceeded a hundred or two, and decayed about the fifth day. They were both ex- tremely sick, but had no convulsive affec- tions. The other two had the eruption to a greater extent, in point of number, but escaped with the same sickness. They were both younger than the two that had been vaccinated, and had the disease before them. This was about the end of June ; the small- pox were then raging in the village, and had carried off three or four children.^ — The disease was introduced by one family, about the middle of May.
Case XIIL— June, 1808.
In consequence of the same information with the preceding cases, I called at the same time upon the family of John Eal, la- bourer in the same village. I found five children, in all, had the small-pox, and were then nearly over with them. Only one of
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this number had been vaccinated, which was done by me when she was about nine months old, has now a very large cicatrix, and the mother says that she distinctly recollects its being severely inflamed, and that I expressed myself well pleased with its appearance. At this period she was now six years old, was at- tending school, and sickened before any of the family ; had a very considerable num- ber of small-pox, which went through the regular course of the disease, and now has left a great number of pits. One of the other three sickened the day following, but the other two, not until eight day^ after.
Case XIV.— June, 1808.
I also attended the family of John Wood, in the same village, who had two children vaccinated by Mr Gillespie, surgeon in E- dinburgh, about the month of March. A- bout the end of June following, one of them, aged two years and a half, sickened, had
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three distinct convulsions, and in about the end of two days, extreme sickness and dis- tress, a rash made its appearance, followed with a few pustules, which kept out three or four days. The other, the oldest, did not complain. Mr Gillespie vaccinated nine or ten that day ; her arm was distinctly inflam- ed, and the vesicle very large. The cica- trix is very distinct, and fully as much so as her sisters.
Cases XV. and XVI.— June, 1808.
Margaret Proudfoot, in the village of East Duddingston, was vaccinated by Mr Stevenson, surgeon in Gilmerton, when about three months old, who expressed himself perfectly satisfied at the time. The mother also says it was a distinct vesicle, well inflamed, and the scar is now large. In the month of June last, she fell sick, which, after continuing about two or three days, was ucceede4 with au eruption to the
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extent of one or two hundred — they did not decay until the fifth day. She was now about seven years old, and was attending school. She had a brother now eight years, and had also been vaccinated by the same gentleman ; he became sick, and continued so for two days, but was followed with no eruption. The small-pox were very preva- lent in the village. The family, at the time, consisted of other two children, who had been inoculated, but did not complain in the smallest degree. Mr Stevenson also saw the child when the pustules were upon it, and said he thought it w^as the chicken- pox; they were not, however, known nor heard of in the village, at that time.
Case XVII.
Elisabeth Saffley, now aged five and a half, was vaccinated from the pustule of a neighbour's child, by the mother, when about three years old. The child from
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which she was vaccinated, was under the care of a regular practitioner, who declared it the genuine disease ; and, from its look- ing so well, the mother was tempted to try it. The virus produced a vesicle, and was considerably inflamed, and has now a dis- tinct and large cicatrix. From the month ot June, the small-pox, as has been already noticed, were prevalent in the village of East Duddingston. She was attending school ; she sickened, and after two days sharp fever, was succeeded with a. rash, but no eruption. Previous to his complaining, a child in the same family, who was never vaccinated, became sick, and had a copi- ous eruption of distinct small-pox. There was no other cutaneous disease known at the time in the village, and no other of the family complained in the smallest degree. They were three in number, and had all undergone the small-pox.
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Case XVIII.— June 1808.
In the latter end of June, I was desired to visit tlie son of Alexander Carse, labour- er, Niddrie-mill. I found him covered all over with small-pox of the distinct kind, of a very large size, and then about the seventh or eighth day, and just decaying. The number of the pustules must have ex- ceeded a thousand ; he was extremely sick for two or three days before the eruption made its appearance. He was then about nine years old, and was vaccinated by me when four. His arm had the usual ap- pearance, matter was taken from it to vac- cinate others, and the scar is of the com- mon size. The small-pox were epidemic in the village at the time, and made their appearance there about the beginning of May ; none had died ; he was attending school. He had a sister about thirteen years old, who lived in the same house, but
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did not attend the school, who was neither inoculated, nor vaccinated. She became sick in about eight or ten days after him, and went through the disease much in the same way, but to a greater extent.
Cases XIX, XX, and XXI.— June 1808.
James Muirhead, labourer, Niddrie-mill, had three children, a boy, and two girls, vaccinated by a smith six years ago, and by the description, as well as appearance of their arms, seemed to have gone through the disease in its common form. They had
daughter now aged ten, who had been inoculated when about a year and a half old, by a practitioner in this place, but did not succeed. She was also vaccinated at the same time with the other three, but it also did not succeed. All four attended the village school. The boy fell sick, and after continuing so a day or two, an erup- tion made its appearance, in number a-
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bout a hundred ; they came to very httle suppuration, and decaj'^ed about the fifth or sixth day. In about five or six days af- ter, his pustules Avent off ; the other two sisters, who were vaccinated along with him, fell sick, but had an eruption, neither so numerous, nor so long standing. The oldest gnrl, who neither received the in- fection from inoculation, nor vaccination, escaped without the smallest complaint.
Case XXI II.— July 1806.
Elisabeth Kedzlie was vaccinated by a practitioner in this place, when about three or four months old, and, according to the re-^ port of the father of the child, and also its grandmother, expressed himself at the time satisfied, of its having gone through the most perfect form of the disease. In the month of July the small-pox were epidemic in the village of Monckton, and at this time she was then four years old. She became
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sick, and after continuing very feverish for some days, an eruption followed, to the ex- tent of a thousand, or fifteen hundred pus- tules, which after going through all the re- gular form of small-pox, did not begin to decay until the eighth day.
I was called in soon after the eruption made its appearance, and although this dis- ease was of the distinct kind, yet from the extent of the eruption, considerable fever occurred at the latter period of the disease, and not entirely destitute of danger. I de- sired the medical gentleman should be in- formed of the case, that he might satisfy his curiosity, and, upon visiting her, he w^as con- vinced of its being a distinct case of small- pox, and again expressed his conviction of her having gone through the genuine dis- ease. She had a brother who lived in the same house, who was vaccinated also when a few months old, and was at this period two years, but was not in the least affected.
m
Another girl in the same house had been vaccinated twice when a few months old^ without any effect, and at this period, being four years and a half old, she became sick, and continued for three days, but followed with no eruption. The family consisted of other three, who had been all inoculated, but had riot the smallest complaint.
Case XXIIL— January 18Q9.
Isabel Hope was vaccinated by Mr Ste- venson, surgeon in Gilmerton, when about three months old. She is now near six years, and had the chicken-pox when about two years and a half. Mr Stevenson was well pleased with the vesicle, from Mrs Hope's account, and from her own me- mory she says, that it was a large pock, and very much inflamed, and the cicatrix is still very large. The small-pox made their appearance in the parish of Newton about the beginning of January, when several
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children who attended the school were in- fected. She was also there, and became sick, which, after continuing two or three days, ended in an eruption of pustules, about a hundred in number. They began to decay about the fifth or sixth day. There are two more children in the family, both younger, and who have 'been vaccinated- None of them have yet complained. None of them attend school.
Cases XXIV. and XXV.— Jan. 1809.
I was requested to visit the son of Mr B. farmer nearMonckton. I found him labour- ing under the mc/st excessive fever, accom- panied with great insensibilitj^ and stu|X)r, with some twi'cching of the muscles. I or- dered what 'apperired proper for his situa- tion, but with Uttle or no benefit, until a copious eruption of about five hundred va- riolous pustuies made their appearance. They went " through the regular progress.
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and did not begin to decay until the seventh day. He is about six years and a half old, and was vaccinated by me when about six months ; and, from my own recollection, as well as the mother's, the vesicle was large, much inflamed, several lancets were infect- ed from it, and the cicatrix is now quite di- stinct. At the time he was affected, as above described, he was attending Newton school, where the small-pox were epidemic to a considerable extent, and no other dis- ease prevalent of an exanthematous nature. His sister, now about three years old, was also vaccinated by me when four months ; in about eight days after the erup- tion made its appearance on her brother ; she fell sick, and continued so about two or three days, which was succeeded with a rash, but not followed with any eruption*.
* The same day she became side, 1 had inoculated her from her brother, b.ut in consequence of the occurrence of the fever, an efflorescence followed to a censidcrable extent, in less than twenty-four hours, and no pustule foUowefl.
Case XXVI.— January 1809. •
Mary Paterson, in the village of Iriveresk, was vaccinated by me when eight months old ; is now three years. From my own re- collection, the mother's description of the arm, lancets being infected, and a large ci- catrix, there can be little doubt of her hav- ing undergone perfect vaccination. She sickened about the beginning of Januar}', and, after remaining three days very dis- tressed, a rash followed, attended with about a dozen of pustules, which, however, did not keep out above four days. In about three days after, a younger sister, about five months old, was affected, and, in a few days, was followed with an eruption to the extent of some hundreds ; she was not vaccinated. The small-pox were prevalent in the neigh- bourhood, and no other exanthemata known, at the time.
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Case XXVII.— February 18(^.
Hearing that the child of one M'Donald, in the village of Inveresk, was labouring under the small-pox, after having been vac- cinated, I called, and found her to have some hundred pustules. She is now up- wards of five years, and was attending school where many children had gone away sick, and afterwards followed with the small- pox. They are now epidemic in the vil- lage. They maturated as usual, and began to decay about the sixth day.
The child was vaccinated by Mr Graham of Dalkeith, when about a month old ^ from the father and mother's description, it would appear to have been a large ve- sicle, and very much inflamed, and has now left a very distinct, and extensive scar. ■ Mr Graham saw it three or four times du- ring the progress of the affection, and ex- pressed himself well pleased with it.
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Cases XXVIII, XXIX, anb XXX, January 1809.
John Owen, in the parish of Newton, had two children vaccinated, when about six months old, the oldest by me, and the other by a Mr Armstrong, formerly sur- geon to the Edinburgh militia. The oldest is now seven, and the other six years of age. To the best of my recollection, the vesicle was distinct, with a large areola, and I expressed myselfj by the parents' account, perfectly satisfied. They give the same account of the other arm, and add, that it was fully more inflamed; both have now a distinct cicatrix. The eldest became sick in the beginning of January, which, in two or three days, was followed with about two hundred pustules, which began to decay about the fifth or sixth day. The other sickened in ten days after, and was follow- ed with a very numerous eruption, at least
M
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exceeding a thousand, the blains of which are still visible, and they did not decay un- til about the eighth day. They both at- tended the village school, and the small pox were prevalent, and fatal in the neigh- bourhoocL They had also a younger child, now about four years, who was vaccinated by Mr Simons (then assistant surgeon of the same regiment) when about one year old^ ,.She also became sick a few days af- ter the second, and, after continuing about two days, went off, without being followed with any eruption. Her arm has the same appearance with the other two, and in the parents' opinion, went exactly through the same course.
CASE XXXL— January 1809.
James Jardin, in the parish of Newton, has had three children vaccinated by Mr Stevenson, surgeon in Gilmerton ; the oldest is now seven, the second six, and
179'
the youngest three years old. The two oldest were vaccinated when about eight- een months, and the youngest at twelve. The oldest sickened about the middle of January, which was followed by an eruption of about six hundred pustules, which did not begin to decay until the seventh day ; the other two have not as yet complained. The mother says, that sh6 distinctly remembers the appearance of the vesicle, and describes the areola to have exceeded a half-crown in circumference. Mr Stevenson also expressed himself well pleased with it at the time. The two old- est were attending school, and the small- pox were both prevalent and fatal all round.
Cases XXXII. and XXXIII. February 1809.
Alexander Cairns, in the parish of In- veresk, has had two children vaccinated ;
180
the eldest of whom is now past seven, and was vaccinated with one puncture, by a practitioner of this place, when about two years old ; the other is now six, and had the vaccine disease when about twelve months old; he was vaccinated in both arms by Mr Gibson, formerly of the Dum- fries-shire militia. The parents say both their arms had the same appearance, hav- ing a vesicle, and a large circular inflam- mation ; the crust fell off in about a fort- night after, and the scars are now equal- ly distinct. They were both repeatedly visited during the ]Drogress of the disease, and both the gentlemen expressed them- selves perfectly satisfied. On the 19th of February the oldest sickened, and, after being confined to bed two or three days, an eruption of several hundred distinct pus- tules took place ; they were maturated by the sixth or seventh day. This boy only attende^l school, and the small-pox were
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181
prevalent all round. The other has not yet complained.
lOth March. — I was requested to call, as the other had been sick for some days, and found an eruption had made its appear ance, to the extent of two or three dozen, with a considerable rash upon the skin. In three or four days after, the pustules began to decay, and were nearly gone by the fifth or sixth day. A child about eighteen months old, who had never been vaccinat- ed, fell sick at the same time, and had an eruption of distinct pustules, to the extent of some hundreds, and got safely through the disease.
Cases XXXIV, XXXV, and XXXVI. 19th February 1809.
James Robertson, smith, in the village of Inveresk, had three children successively vaccinated by me, when a few months old. From my own recollection, and by the pa-
182-
rents' report, the vesicles were distinct, and attended with large areolae ; the crusts fell . off in twelve or fourteen days after the ter- mination of the disease ; and the scars on all of them are now equally distinct. The oldest is upwards of seven years, the second five, and the third three. The two oldest attended school, and sickened on the same day, which, after continuing two or three days, an eruption of some hundred pustules took place in the oldest, and in the other about two dozen. Those upon the oldest turned in about six days, and the other in about four or five. The small-pox were prevalent in the village, and one or two had died. The youngest has not yet com- plained. March 10th.— Was requested to call, and was informed the third and young- est became sick on the 6th, and, after con- tinuing two or three days, was followed with an eruption of about two dozen of pustules, attended with a rash. They de-
183
cayed in a few days. She was not so sick as any of the other two, but started consi- derably, and was generally confined to bed.
Case XXXVIL— December 1808.
John King, in the parish of Newton, has had three children vaccinated. The oldest was done in both arms by Mr Simpson, surgeon in Dalkeith, when about three months. The other two, in one arm, by Mr Stevenson, about the same age. From . the report of the parents, Mr Simpson was perfecdy satisfied of the vesicles being per- fect, and they also recollect that the ap- pearance of the vesicles were large, and much inflamed. They afterwards formed into dark scabs, and have now left two scars. They give the same account of the other two, and knew no difference in the appearance betwixt any of their arms. The oldest is now seven years, the second past three, and the youngest past two. The
184
oldest sickened about the latter end of De- cember, which, after continuing extremely severe, was followed with an eruption of about forty pustules. The pits of several are still visible. They began to decay about the sixth or seventh day. The small- pox was prevalent all round. He did not attend school, but played with those that had the small-pox, and went freque^itly into their houses. None of the others could be perceived to complain,
Cases XXXVIII. and XXXIX. February 1809.
James Galle}^ in the parish of Inveresk, has five children, the two oldest had the smallrpox by inoculation, the next two were vaccinated, and the youngest had under- gone neither. The two that were vac- cinated> w^ere under the care of two medi- cal practitioners in this place, and from the report of the parents, had both the vesicle, and areola, and their arms have now a dis-
185
tinct cicatrix. The medical gentlemen ex- pressed no other opinion, but that they had undergone the perfect form of the disease. They were vaccinated when about six months ; the oldest is now six years, and the other past three. Upon the 21st of Fe- bruary, the oldest was evidently sick, and the eruption made its appearance to the extent of some hundreds in twenty -four hours after. She kept her bed during the whole progress of the disease, and the ma- turation was not completed until about the eighth day. The other sickened two days after, which was accompanied with a rash, and then followed with a dozen or two of pustules, which did not maturate, but de- cay ec' in about three or four days. In about ten days after, the remaining child, about twenty months old, became sick, and was followed with an eruption, to the ex- tent of some hundreds, which went through the most common form of the disease.
186
The two children that had been inoculated had not the smallest complaint. The small-pox were prevalent in the neighbour- hood, and the mother had often visited a child that died of the disease. The same medical gentlemen attended the whole, and from the parents' report, had no doubt of their being cases of small-pox.
Cases XL. and XLL— March 1809.
James Caddel, mason, parish of Inveresk, has six children, four of whom still conti- nue with him, the two oldest of which had the small-pox in the natural form, up- wards of eight years ago ; the oldest of the other two is four years and a half, and the youngest past two. The oldest was vac- cinated by me, when four months old, in the arm, and the other by Mr Keith, sur- geon of the Berwickshire militia, in both, about the same age. I recollect perfectly, that the vesicle and areola were quite cha-
187
racteristic ; and the mother describes, that the areola in both were equal to the size of half a crown, and that Mr Keith saw the arm in its progress, and expressed himself satisfied of the child having passed through the disease. The scars are very distinct. They both sickened about the l6th March, had considerable fever for three days, which was followed with an eruption of several dozens of pustules upon each, and, after an imperfect maturation, decayed in six days. The family of Cairns were in the immediate neighbourhood, and the small-pox prevail- ins: all round. None of the other children complained in the smallest degree,
Case XLIL— Mai^ch 1809.
James Drysdale, in the parish of Inveresk, has six children ; the four oldest had the small-pox from inoculation ; the fifth was vaccinated by me when six months old, and is now past five years; the sixth is now about
188
two, and has neither been vaccinated nor inoculated. The one that was vaccinated sickened on Sunday the 12th, and continu- ed until the Wednesnay evening following, so extremely distressed, as to appear coma- tose, and the stomach rejected every thing. An eruption made its appearance on the Thursday morning, to the extent of at least five hundred, and did not begin to decay until the seventh day. He continued in bed two days after the appearance of the eruption. From my own recollection, and the mother's account, the inoculated vesicle was large and distinct, attended with consi- derable inflammation, and the cicatrix is now very large. The youngest has hither- to not complained, and none of the rest of the family have ailed in the smallest degree. The small-pox are epidemic all around.
April 3d. — I again called, and now found the child covered with a copious eruption of distinct small-pox, which had only made
189
their appearance the preceding day. Slie had been sick for three days, and was now considerably reheved ; the eruption conti- •nued to maturate until about the eighth day, and then began to decay. Still none of those complained who had passed through the small-pox.
Case XLIIL— March 1809.
James Deans, fisher, Prestonpans, has seven children in family; six had the small-pox from inoculation, and one was vaccinated by Mr Williamson, surgeon in Prestonpans, when one year old, and is now about five. It would appear from the arms that he had been vaccinated in two places in each arm, and, from the mother's report, all put on the appearance of pocks, attended with j^reat inflammation, and Mr William- son repeatedly infected lancets from them. He sickened about the seventh of March, and,after remaining for three days, extremely
190
distressed with the most severe fever, an eruption to the extent of some hundreds made its appearance, which continued to maturate until the seventh day, and then began to decay. When I first saw him, the crusts were nearly all fallen off, but both pits and blains were perfectly distinct. Mr W. had seen the child, but, from the mother's ac- count, did not distinctly allow it to be small- pox. I saw him a second time, when the blains and other appearances were follow- ing the usual progress, and the parents, and the whole neighbourhood, expressed them- selves perfectly satisfied of its having been, a most evident, and distinct case of small- pox. None of the rest of the familj?^ were in the smallest degree affected, and the small-pox had made their appearance in the neighbourhood.
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191
Cases XLIV. and XLV.-tMarch 1809.
James Hunter, fisher, Prestonpans, has three children ; the oldest is six years, the second past four, and the third two. The two oldest, from the mother's account, were vaccinated at the same time, upwards of three years ago, by a Mr Nicol, assistant- surgeon in the Berwickshire mihtia, in both arms ; and, from the mother's description, the vesicles were large, attended with great inflammation, and the scars in both arms are now distinct. The youngest of the two sickened on Sunday the 26th March, and, after remaining in bed two days, attended with vomiting, startings, and other symp- toms of exanthemata, an eruption appeared to the extent of a hundred, which maturat- ed in five days, and then rapidly decayed. The oldest fell sick on the Wednesday fol- lowing, and at the time I saw the other, was confined to bed, and had been so for two
192
days. Me was extremely sick, and affected with starting, sneezing, and other sj^mptoms of eruptive fever. When I called, three days after, the sickness was gone, and no pustular eruption had followed. The young- gest had not then complai ned. None of the children were at school, but two cases of small-pox were in their grandfather's, at a little distance, and they were prevalent in the village.
Case XLVL— April 1809.
A Mr S. in the parish of Inveresk, has had three children successively vaccinated, by a practitioner in this place. The oldest is nine years, the second seven, and the youngest five. Both the parents state, that no objection whatever was started by the medical gentleman to any of the cases, that he was perfectly satisfied, and they declare that the arms of the whole went through the same course, having all a distinct pus-
193
tule, or vesicle, attended with a large ' areola, and the scars are now distinct. On Sunday, the 2d of April, the young- est became sick, which, after continuing with all the usual symptoms of variolous eruptive fever, for two days, was followed with an eruption to the extent of two or three hundred, which continued to maturate until the fiflh day, when they began to de- cay. She was five months old when vacci- nated ; was attending the common parish- school, and the small-pox in the immediate neighbourhood. The other two have not yet complained. The family consist of four more, who were all inoculated, and have not had the smallest complaint. The medical practitioner who vaccinated the child also saw her with the eruption, and, from the mother's account, allowed it to be small-pox.
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194
Case XLVII.— April 1809.
Alexander Wilson, in tiie parish of Pres- tonpans, has two children ; the oldest is now five years, and was vaccinated by Mr White, surgeon in Dysart, in one arm, when six- teen months old. From the mother's ac- count, the arm had a large vesicle, and was accompanied with so much inflammation as to extend to the circumference of a half- crown ; the cicatrix is now large and dis- tinct. The other child had neither been vaccinated nor inoculated, and about the end of March became sick, and had a very copious eruption of small-pox. - Being next door, I called, and found the circumstances as already stated, and requested the mother might be attentive to inform ine if the old- est should become sick. Accordingly, in ten days after, 1 was informed he had been complaining for two days, and some dozens of pustular points had made their appear-
195
ance. I called next day, and found the eruption distinct, but small, and they decay- ed in about four days; the small-pox were prevalent all round.
Case XLVIIL— April 1809.
Mr D. in the parish of Inveresk, has four children, tKe oldest of whom was inoculated, and the other three vaccinated. The old- est of the three is past ten, the second past eight, and the youngest five years of age. The two oldest were vaccinated by me at the same time, and the youngest by her- self The oldest and youngest are now at Dalkeith. On Saturday, the first April, the second, aged eight, appeared sick, and, after continuing extremely distressed for nearly three days, an eruption made its appearance to the extent of a thousand, or fifteen hun- dred, distinct pustules, and continued to maturate until the seventh or eighth day, and then decayed. She was vaccinated
196
when about four months old, in both arms, but ohly one succeeded ; and, from my own recollection, and the mother's account, the arm proceeded through all its stages, and has now a distinct cicatrix. She attends a common school in the immediate neigh- bourhood, crowded with children; the small- pox have been prevalent in the village, and 6ne or two have died almost next door. The one that was inoculated has not com- plained.
197
Sect. II.
Cases of Inoculation after Vaccination.
When T commenced the practice of vac- cination, in common with most practition- ers, I inoculated them a few weeks, or months after. This I continued to do, to the extent of thirty or forty cases, when finding the appearances nearly similar, I desisted. In these trials, the arm put on the following appearances : During the first three or four days, the punctured point was elevated, and a little inflamed, and had the same appearance as if no previous vac- cination had existed ; from the fourth to the sixth day, it still became more elevated and inflamed, but its progress less rapid than where no vaccination had taken place, and its point vesicated, but without any pustular
198
appearance ; from the sixth to the eighth, ninth, or tenth day, it acquired a pretty large conical figure, a good deal inflamed, but still without any pustular form ; after this period, it rapidly decayed, and in a few- days disappeared, without leaving any scab or scar. In some cases it only gained the appearance as described, at the sixth day, and then decayed. In none of these trials were there ever the smallest appearance of a pustule, but frequently the point of the tumor presented the appearance of a small shining watery vesicle. In no case, were there the smallest shew of a circular inflam- mation, or areola, and no constitutional af- fection whatever.
After these trials, and the concurring tes- timony of other practitioners, and publica- tions on the subject, I did not consider it necessary to persist any farther in these ino- culations, and, from the year 1800, until last summer, I did not renew this practice.
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Cases L and II. Immediately, however, after the occur- rence of the first four cases already inserted in this work, I thought it my duty to avail my- self 6i' every opportunity for renewing these inoculations ; and accordingly, with virus ta- ken from the girl there mentioned,! inoculat- ed a boy and girl in one family, who had been both vaccinated by me when a few months old. They had been both punctured in two places on the same arm, and went through vaccination in the most perfect form ; the areola being large, lancets were infected from them ; and the mother thinks, to the best of her recollection, they gave symp- toms of sickness, and the scars are now large. The boy is upwards of five, and the other four years of age. Both the inoculat- ed arms advanced steadily, and, by the eighth day, assumed the appearance of a moderate- ly elevated and inflamed tumor, with a pus- tule upon the point, but containing little vi- rus : from tlie eighth to th^ eleventh day.
200
the inflammation rapidly extended in cir- cumference, and the pustule much increas- ed in diarneter, but not containing much virus. It now, in every respect, resembled a variolous inoculation in a state of perfec- tion, and, accordingly, was followed with constitutional symptoms. The boy became sick, and continued feverish for three days, with frequent starting, and at last an erup- tion of about a dozen or two of inflamed elevated points were observed — they on- ly remained out three days, and then dis- appeared ; there was a rash previous to the eruption. The girl's arm went through nearly the same course, but not to so great an extent ; and, although sick, she had no rash nor eruption.
Cases III. and IV.
With virus taken from the pustule on the boy's arm, I infected tw^o children, one of whom had been vaccinated by Mr Benja- min Bell^ and the other by myself^ when a
201
few months old. The oldest was now near six, and the other about three ; both the arms inflamed, and nearly arrived at the same appearance as already described in the other two cases ; the pustules had less .appearance of virus, and the circular inflam- mation not quite so extensive ; but the pus- tule and circular inflammation was consider- ably more distinct, and extensive upon the oldest, than upon the arm of the youngest. They had a trifling degree of sickness for one da)^ and no eruption followed.
Cases V. and VI.
No farther opportunity occurred until some months after, when, with virus taken from a natural pustule, I inoculated two boys, the one aged six, and the other eleven years. The youngest was vaccinated by me when a few months old, the other about two years ago when in Jamaica. The arm of the one, to my recollection, went through the regular progress, and the scar is now very distinct
202
The other recollects perfectly of his arm having a large vesicle, and being very much inflamed ; that a very great number were vaccinated from him ; and that the practi- tioner assured his mother of his being secure against small-pox. The mother, however, on his being sent to this country, requested he might be inoculated, upon the small- pox being epidemic in his neighbourhood. Both the arms advanced nearly in the same manner until the sixth day, when the young- est assumed a more pustular appearance, with a broader base, and from the eighth to the tenth day, had an extensive circular in- flammation. He, however, did not appear sick, and there was no eruption — a scab fol- lowed the pustule, and dfecayed as usual. The other, from the sixth day, advanced with a high conical appearance; the inflam- mation confined to the tumor itself; no dis- tinct vesicle, and no areola whatever was produced ; it however continued to increase until the tenth day, and then decayed. No
203
effect whatever was produced on the consti- tution, and it left no scab.
Cases VII. and VIII.
At this period I had a.nother opportunity of repeating this experiment. Two children
of a Mr L 1 had been both vaccinated
by me when about three months old ; the oldest was now three j^ears, and the other nearly two. They were inoculated with the same virus, and on the same day. Their arms put on the same appearance until about the sixth day, when that of the oldest ob- tained a pustular point ; and from that day, until the tenth, it gradually became more elevated and inflamed, until it gained the extent of a shilling ; but the pustule was small, and containe.l little or no matter, and no constitutional effect could be detected ; it decayed in a few days, and was followed by a small scab. The other never assumed any pustular appearance, but continued to gain a considerable elevation and extent, until
^04
the ninth day, when it rapidly decayed ; it was attended with no febrile symptoms, and left no scab.
Case IX.
In consequence of the frequent occurrence of small-pox succeeding to vaccination, I was requested to inoculate the child of a Mr H. who had been vaccinated by me when six months old, and is now six years. Both Mrs H. and I recollect distinctly, the ap- pearance of the arm ; the vesicle was per- fect, the areola very extensive, and the cica- trix is now large. On Monday the 13th March, I introduced, by one puncture, some very active virus, and on the Wednesday following, the punctured point was distinct- ly elevated and inflamed. I again examin- ed it on Friday alternoon, and found it had now acquired a pustular point, and the ino- culated tumor considerably inflamed, and much increased in size. Next day I found the pustule had been ruptured during the
205
course of the night, the tumor much en- larged, and surrounded with an erysipela- tous inflammation, to the extent of a shiUing. On Sunday the inflammation had extended considerably, and the point of the tumor had again acquired the appearance of an imperfect pustule, was dischargin^j an ich- ory matter, and the child was now evi- dently sick and feverish. Next day the fe- ver had increased so considerably, as to take away all appetite for food, and produced an inclination for keeping the bed. The arm was now extremely inflamed, accompanied with an areola to the extent of a penny-piece, and continued oozing out the same matter ; a few inflamed points could also be seen making their appearance, a considerable dis- tance from the inoculated spot. In two days after, the fever was quite gone, the in- flammation much abated, and the pustules round the inoculated spot, to the number of a dozen, were proceeding to maturation.
206
Case X.
Mr L. had two children vaccinated by- Mr Stewart, Surgeon in Kelso, at five months old, one of whom is now six and the other four years of age. Mrs L. says she remembers the appearance of their arms perfectly ; that the vesicles were large, and accompanied with an extensive circular in- flammation, exactly corresponding with what she has since observed in other two of her family. Mr Stewart was also perfectly satisfied, and the cicatrix is very distinct on both arms. On the same day with that of Mr H.'s child, I introduced the same small- pox virus by one puncture. On Wednes- day the 15th, both punctures had evidently taken effect, and on the day following, the puncture on the arm of the oldest was sen- sibly increased in size, and beginning to as- sume a vesicular point, but on the arm of the youngest, the inoculated spot had su§-
207
tained some injury during the night, and appeared scabbed. On the 18th, the inocu- lated point upon the oldest was now much increased, and its extremity presented the appearance of a number of small vesicles, but giving no appearance of a distinct pus- tule ; the inoculated spot upon the arm of the youngest seemed decaying, and attend- ed with a crust. On Monday the inoculat- ed spot was highly elevated, and inflamed, with a cluster of vesicles on its point, evi- dently containing virus, but still giving no appearance of a perfect pustule, and an are- ola was now beginning to form ; the arm of the youngest was now nearly well. On the day following, a beautiful areola now ex- tended itself to the circumference of a half- crown, and the vesicular point was large and distinct, and nearly formed a perfect pustule ; the child now appeared unwell, her pulse was much quickened, the skin hot, her countenance pale, and wanted her usual
208
appetite and spirits ; she, however kept going about. These appearances continued for two or three days, when the areola be- gan to decay, and a scab formed upon the point of the inoculated tumor.
Case XII.
On Wednesday, the 22d of March, I ino- culated the child of Mrs H. with limpid variolous virus, taken from a pustule of the epidemic disease. She is now seven years of age, and had been vaccinated by me at four months old. Both the mother and I xecoHect perfectly, that the vesicle was dis- tinct, attended with a circular inflammation to a great extent, and the scar is now very large.
Upon calling, on the Saturday following, the punctured point was more advanced than common, was much elevated, and in- flamed, and its point evidently vesicular, J again visited her on Tuesday, when the
209
vesicular point had become a small but dis- tinct pustule, and the inflammation begin- ning to extend round it. On Thursday the 30th, I found her in bed, extremely sick, accompanied with much heat, headach, and thirst. Her mother informed me she had been very much affected from the Wednes- day morning, and had frequent vomiting. Upon examining the arm, the pustule was still small, but contained virus (with which I infected a lancet), and was attended with a jagged areola of a deep red colour, ex- tending to the circumference of a halfpenny. Upon examining the body, I perceived se- ^ eral pustular points, and a considerable 1 redness. Saturday. — This was the first day she had been out of bed, from the first at- . tack of sickness. Upon examining the arm, it had assumed a very distinct pustular ap- l)earance, and contained virus sufficient for infecting two, or three lancets, and the are- ola was an extremely deep, and bright red,
o
2iO
extending to the circumference of a penny- piece, irregular and jagged. The body was now covered all over with a measly rash, and a dozen and a half of distinct pus- tules could be counted upon the body. Tuesday. — The rash was now gone, the pus- tules perfectly distinct, and proceeding to maturation, and the arm in a state of de- cay.
Case XII.
The child of a Mr M. in this place, had been vaccinated with one puncture in each arm, when about six months old, by a prac- titioner in this place, and the scars are now large and distinct. In consequence of the prevailing reports, she was inoculated by the same gentleman, with recent, and ac- tive small-pox virus, on the 4th of April, be- ing then about six years old. I was per- mitted to see the arm, and, on the Saturday Ibllowing, the inoculated spot had gained a
211
considerable size, was very red* and had a vesicated point, with the crust, from the punc- ture, on the centre. On Monday, the vesica- tions had all nearly united, and formed a distinct pustular appearance, but neither so large, nor extensive, as takes place in cases of j)rimary inoculation ; it contained evidently a small quantity of transparent virus, and a small and faint areola could be distinguished. Tuesday. — The appearance of the pustule was much the same, but larger and more perfect, with the scab or crust in the cen- tre, the areola considerably increased, and of a much brighter red. No constitution- al symptoms could be detected ; a slight heat appeared upon the skin, but little* or no alteration in the pulse. Wednesday .-The pustule much the same ; the areola as large as a penny-piece, irregular and jagged. From the report of Mrs M. and the maid, she had sneezed repeatedly, which they ijttributed to cold, and her appetite ap^
212
peared impaired. Upon counting the pulse, it was exactly 108, and, to my feelings, a slight heat appeared upon the skin. Thurs- <jay.— The areola of a deeper red, rather more extensive, and much jagged. The pustule appears somewhat decayed. She had sneezed some the preceding night, on- ly drank tea to breakfast, but eat no bread. Her pulse exactly 98. Friday. — Both pus- tule and areola much decayed, her appetite still indifferent, and ii^ other respects much the same as yesterday. Monday. — The areola quite gone, and the pustule scabbed.
213
Sect. III.
Cases of Small-Pox conjoined with Vaccination.
Case I.
Although I have frequently met with instances, where small-pox occurred a few days after the introduction of the vaccine virus, yet I considered them as entitled to no more attention, than those cases, where the natural small-pox occurred, after ino- culation. The following case, however, appears to me entitled to more attention, as it bears upon certain points contended for, both by the author of the practice, and other writers upon the subject.
Wilson's child was vaccinated when
about fourteen months old by a practition- er of this place. From the mother's ac-
214
count, the arm went on in the usual way, and, on the ninth day from vaccination, a most regular, and perfect vesicle, with a little circular inflammation, existed. Virus w^as at this time taken by the same gentle- man from the arm. On the same da}'', however, the child was evidently sick, and on the next, a copious eruption made its appearance, which soon proved to be con- fluent small-pox. It was two, or three days after the eruption, that I had an opportu- nity of seeing the child, and the vesicle on the vaccinated arm was large, and much inflamed, and assumed every appearance of the perfect vaccine disease. The child died. The small-pox were epidemic in the neighbourhood.
Case II.
I was requested to inoculate the child of a Mr D., and, on Sunday the 12th March, I introduced by puncture, variolous virus
215
into the right, and vaccine virus into the left arm. Each virus was Hmpid, the va- riolous was from the same source with that used in the cases of Mr H. and Mr L.'s children ; the vaccine was taken from a ve- side on the eighth day. The Tuesday fol- lowing, both punctures had evidently taken effect, and presented exactly the same ap- pearance, when inspected with the assist- ance of a good glass ; being red and ele- vated above the rest of the skin, and the structure of the skin rendered very distinct, by the inflamed point appearing like little vesicles or cells. On Thursday, both punc- tures were - much enlarged, and present- ed the appearance of a distinct vesicle, or pustule, but small, and evidently cellu- lar within. When again inspected on Sa- turday, the cow-pox vesicle was large, at- tended with a small circular inflammation, and seemed at least twenty-four hours far- ther advanced than the variolous pustule.
216
which, although much increased in size, and its circle jagged and unequal, had not the smallest circular inflammation. On Monday, the 20th, 1 found the child very- sick, and was informed she had appeared un- well on the forenoon of the preceding day. The cow-pock arm was now beautifully cha- racteristic, having a most perfect vesicle, and a complete double areola, extending about the size of a halfpenny^ and exactly circular. The variolous pustule was now jagged, and irregular in two places, and at- tended with an erysipelatous inflammation, to the size of a small shilling. The depres- sion in the centre of both wasi nearly the same, the cicatrix from the puncture quite evident, but in the vaccine vesicle most ex- tensive. Upon visiting the child again, on Wednesday the 22d, the sickness was abat- ed, and an eruption, to the extent of four or five dozen, had taken place. The cow- pox vesicle was now decaying ; the areola.
217
although perfectly distinct, and of the same size, had faded considerably, and the crust had extended itself over one half of the ve- sicle. The small-pox pustule was still at- tended with inflammation, nearly to the same extent as when last described, and still but little decayed. At my next visit, two days after, the cow-pox vesicle was nearly completely scabbed, and, in the small-pox pustule, the crust had extended itself over half its circumference, and the circular in- flammation almost gone. The pustules con- tinued to increase, and, in general, arrived at maturation about the seventh day, and both vesicle, and pustule, scabbed in the usual form.
Case III.— March 1809.
Upon Monday the 18th March, the child
of a Mr was inoculated with vaccine
and variolous virus by puncture. The vac- cine was introduced into the right, and the
218
small-pox into the left arm. Both pustule, and vesicle, followed the same course as de- scribed in the preceding case, and the vac- cine vesicle again acquired the areola, full twenty-four hours, before the small-pox pus- tule. On the tenth day from inoculation, the vaccine areola was large, distinct, and circumscribed, and the variolous did not exceed a farthing. The child, however, had become sick the preceding day, and continued so about three days, which was followed with an eruption to the extent of some dozens. The small-pox pustule on the twelfth day, was considerably increased in size, and the areola, exceeded in circum- ference the size of a halfpenny. The cow- pox vesicle was now considerable decayed, the areola had become extremely faint, and both vesicle and pustule followed the same course as described in the foregoing case.
219
Case IV.
On the first of April, I vaccinated and ino- culated in the left arm, the child of a Mr
. The punctures proceeded nearly in
the same manner as has been described in the preceding cases, but with the difference, that the vaccinated vesicle seemed in its progress, evidently behind the inoculated pustule. On Saturday the eighth, the ino- culation was evidently accompanied with a small areola, about the size of a sixpence, and the child appeared a little sick; no areola had yet begun to form round the vesicle. The day following, the child was very sick, the small-pox pustule irregular and extensive, with an areola at least, the size of a shilling. The vaccine vesicle had now acquired a small ring, and, in its other appearances, was perfectly characteristic. On Tuesda}', the sickness was somewhat abated, and about a hundred pustules had
220
made their appearance over the body. The pustule was much the same, but some- what decayed. The vesicle and areola, however, was beautifully characteristic, aad joined the areola formed by the pustule. Thursday,— The small-pox and vaccine areo- la were much faded, the pustules proceed- ing to maturation, and the vaccine vesicle scabbing in the usual form.
CHAP. VII.
INQUIRY INTO THE PRECEDING CASES.
I HAVE already shewn, from an attentive consideration of the phenomena attending vaccination, and several other circumstances connected with that practice, that sufficient grounds are established, for calling in ques- tion every fact connected with its antivario- lous powers. I trust, when, to what has been there stated, we shall add the proof arising from the preceding cases, we will have such an accumulation of evidence, that none but the most obstinate sceptic can possibly resist.
222
I. — Are they to he considered as cases oj Small-pox f
To those who are acquainted with this subject, and are capable of appreciating proof of any kind, I apprehend we might safely trust to the perusal of the cases; but we shall take the liberty to remark, that in the evidence now before us, it is impossible to pommit any mistake. It is perfectly clear, they could be neither hug, nor fiea bites, or the stings of insects, as they were all uni- formly preceded with fever, and followed with an eruption in many cases, arriving at the most distinct character of a small-pox pustule. They also, uniformly, extended themselves, only through that part of the family that had undergone vaccination; whereas, had they proceeded from any of those causes, they would have affected the whole. They were also evidently propa-
223
gated by contagion, and small-pox were universally prevailing as an epidemic. It is hardly necessary to remark, that none of these peculiarities apply to those causes al- ready mentioned ; and if fever at any time is known to follow the stings, or bites, of more powerful insects, there are sufficient evidence of its nature, from the previous ex- istence of the cause, and they have never yet been found capable of producing any pustular eruption.
With regard to confounding them with chicken-pox, I apprehend that no practi- tioner of moderate experience, can possiblj^ at any time, commit the mistake. The chicken-pox vesicle, at all times, differs in so striking a manner from the small-pox pus- tule, that with the least attention, they may be readily distinguished. In less than twen- ty-four hours from the first appearance of the eruption, they acquire the appearance of a vesicle, having a perfect resemblance to
224
any blister produced by scalding, or can- tharides, and in about twenty-four hours more, either burst or rapidly maturate, and present, in their decay, the appearance of a small pointed scab, attended with a dif- fused redness, and slight turgescence, of the surrounding parts ; nor even, upon their first appearance, are they attended with the ele- vation of the surface, which attends the small- pox pustule ; do not give the same hard feel under the finger; and are uniformly destitute of the depression in the centre. * But here
* Dr Heberden describes the Taricella or chicken-pox nearly in the following terms : " The inflammation round the chicken-pox is rery small, and the contents of them do not seem to be owing to suppuration, as in the small-pox ; but rather to what is extrayasated immediately under the cu- ticle, as in a common blister. It happens to most of them, either on the first day that thfe little reside arises, or on the day after, that its tender cuticle is burst ; a thin scab is then formed on the top of the pock, and the swelling abates with- out its ever being turned into pus, as in small-pox."
Dr Willan remarks : That variolous pustules are, on the first and second day, small, hard, globular, red and jjainful, and indented in the centre; the varicella exhibits, on the first
225
we are not left to depend entirely upon the difference in the eruption, we have, over and above, tlie most decisive testimony ; small- pox were epidemic in every direction, and even existed under the same roof, with the most characteristic phenomena ; none of the children in the family affected but those who had been Vaccinated, and neither chicken-pox, nor any other eruptive disease, were known in the whole neighbourhood. If they cannot then be any of those affec- tions, I apprehend it is impossible that they can be confounded with any other. It is evident that they all carry along with them, either in the fever, the eruption, orot'v..
day of eruption, small red protuberances, not exactly cir- cular, and having a flat shining surface, in the centre of vtfhich is a vesicle, of a greater or smaller size, which about the third day is either ruptured, or shrivelled, and if attend- ed with much inflammation, and remain entire, seem to con^ tain a little purulent matter, and by the fourth, have ob- tained a small pointed dark scab. These appearances fully characterize varicella, and distinguish it from the firm and durable eruption of small-pox."
P
226
concomitant circumstances, the most un- doubted evidence of small-pox, and none but the most unreasonable, and perverse vacci- nist, can possibly deny, but that the evidence, in this respect, is most conclusive.
!!• — That they are to be considered as Cases of constitutional Vaccination.
In order to have a clear view of" this sub- ject, it seems absolutely necessary to come to some understanding concerning constitu- tionab vaccination ; and the first question that naturally occurs, is. Are there no cir- cumstances by which, constitutional vaccina- tion can be ascertained to have taken place?
We have already seen, according to the warmest abettors of the practice, that none of the phenomena of the disease are to be depended upon, and that even they contend the tests of inoculation, and exposure to the epidemic, are not decisive of the constitu-
227
tional effect having been imparted. We have also seen, that if these tests are not sufficient, that v^hich Mr Bryce proposes is not entitled to more attention. We may here, indeed, exclaim. What is to be done to extricate ourselves from such a tissue of ab- surdity, and contradiction ? The way, I ap- prehend, is, nevertheless, neither difficult, nor dubious ; we have only to return to the commencement of the practice, attend strict- ly to the phenomena of the disease, and in- dulge in neither speculation nor conjecture.
If, upon the introduction of vaccine virus,: a vesicle is produced^ attended with more or less of an areola, or circular inflamma- tion, continued for two or three days, with> or without symptoms of constitutional de- rangement, we may conclude, that the vaccine virus has exerted every effect upon the constitution it is capable of, and if the . vesicle remains whole, and afterwards forms a dark-coloured scab, or crust, which in two
or three weeks drops off and leaves a scar, we may consider the disease as having run its natural course. If the person is now made to undergo the tests of inoculation, and exposure to the epidemic small-pox, he will be found to resist them both.
It also appears from experience, and the authority of all who have wrote upon the subject, that although the vesicle should vary considerably in size, colour and figure ; the erysipelatous inflammation be of greater, or lesser extent; sometimes circular, and sometimes jagged and irregular, either with, or without constitutional derangement ; and whether or not, a dark-coloured scab is formed, falling off at certain period, and leaving a small or large scar, yet still the same effect is found to be the consequence, and the most perfect resistance given to every test. To say that all this is not enough, that this may be all obtained, and still the vaccine influence not constitutional-
229
ly exerted, is a solecism beyond all compre- hension. It surely cannot be seriously urg- ed, that these effects may be obtained, without the vaccine vesicle exerting any in- fluence ; that the constitutional efiect is ex- erted in the one case, and local in the other, although an equal resistance is made to the same species of proof ; that if the same re- sults are found to follow from one cause, that the one is complete and the other incom- plete ; or that if any difference, or variety in the phenomena, should really constitute a different disease, that still the effect should he the same.
Here again, we may inquire, to what length are their suppositions, and our indul- gence to be carried ? We must remark, that this string of evasions was only brought forward after the occurrence of many cases, inimical to the perfection of the discovery, and are therefore entitled to but little credit. Indeed the vaccinists themselves differ wide^
, 230
ly in explaining this point ; Dr Willan and others, being incUne4 to admit, that a par- tial security may be really obtained fron^ vaccination, exerting an incompleie influence over the system, while Mr Bryce contends^ that if it exerts any, it must be complete. These violent contradictions we shall leave to themselves to reconcile, and shall observe, that as there is nothing more certain in the whole practice of vaccination, than if you obtain a vesicle, attended with an erysi- pelatous inflammation, or areola, whether retaining, more or less distinctly, the cha- racteristics of the disease, you will uniform- ly produce a security against the tests al- ready mentioned. It is, therefore, impos- sible to grant, that such tests can be resist- ed without vaccination having exerted its constitutional effect, and that if such tests are deemed sufficient proof in some cases, they must be considered equally so in the whole.
231
Mr Bryce's singular excuse in order to de- feat this conclusion, is evidently not well founded, and cannot be admitted. He says, that there are many constitutions that may be insensible to the influence of cow-pox, al- though the characteristic vesicle, and pheno- mena are all present, and that such consti- tutions are still liable to the influence of small-pox, but in so mild a way, as to produce an eruption of inflamed papular points, which speedily decay ; thereby meaning to convey, that all those cases where such eruptions have taken place, af- ter vaccination, were merely mild cases of small-pox, and not rendered so, by the con- stitutional influence of vaccination, which he contends, had never in those cases been exerted.
This defence, however, I apprehend it will not be difficult to overturn ; for it is une- quivocally admitted by Dr Willan, and even by the College of Physicians in Lon-
232
don, that such cases have really occurred af- ter vaccination; and I apprehend, also, that the preceding evidence affords the most decisive testimony of the fact. But inde- pendent of these considerations, the observa- tion is quite opposite to all experience. It is well known, that either in the natural or inoculated small-pox, the complete pustular appearance of the eruption does not always take place, and this seems uniformly to de- pend upon the mildness of the symptoms, and extent of the eruption ; but here the resemblance ceases : for, in the first place, these cases are extremely rare ; and in the next, whenever the eruption exceeds a dozen or two, they almost uniformly sup- purate, and go through the characteristic appearance of small-pox. Besides, when the disease is communicated by infection, such a consequence seldom occurs ; for in the instances before us, where the disease was communicated either from a source.
233
which had never gone through vaccination, or otherwise, still, in almost every case, the results was nearly the same, and the pustules in many cases, although exceeding a hundred or two, seldom went through the regular progress. But to all these reasons is to be added, that all the cases hitherto brought forward, uniformly possess the same character ; from which it distinctly follows, that they are rendered so from some cause, and I think there can be little doubt but this cause must be vaccination. It must therefore either be allowed, that it is capable of exerting a partial constitutional influence in many cases, or that it does so in all.
Although we have thus seen that the uni- formity of the phenomena, and the resist- ing the tests of inoculation, and exposure to variolous contagion, afford the strongest grounds for concluding, that vaccination may be considered as having exerted its full powers upon the constitution, still, how-
234
V
ever, the advocates of the practice contend, that the phenomena are so nice of distinc- tion, that none but the most experienced, can undertake to vaccinate with precision.
This too might he more readily granted, if these gentlemen would be so good as con- descend to notice, what really are the ap- pearances to be depended upon. But when we find that all of them admit, that every one of the phenomena may readily undergo every possible variation, that not one cir- xumstance can be pointed out, as capable of . characterizing its existence, and that all the variety of appearances, and other cross and untoward accidents, attend the 'practice, even when in the hands of Dr Jenner or others, who contend for superior informa- tion, whether derived from more extensive practice, or more accurate observation, it is impossible to find out upon what grounds tliey can insist, that experience has any ad-. yant9.ge.
235
Waving this entirely, and leaving it to the vaccinists to. determine, I apprehend we may derive some assistance from our ex- perience in the practice of inoculation. The difference betwixt the practice of vaccina- tion, and inoculation, is by no means so great as to throw away as useless, all that information which our former experience certainly imparted. I contend, that the phenomena, so far as they depend upon the vesicle, and pustule, enabling us to judge of their producing the constitutional effect, are exactly the same. It was well known to those who had any experience in the practice of inoculation, that every variation of the pustule and areola, were still capable of producing the constitutional influence. You might have every variety already no- ticed, as occuring in vaccination, and still - the constitutional disease imparted in its greatest perfection. The areola was here looked upon as the decisive test of its influ-
236
encing the system, and as a proof of the perfect satisfaction that existed, no body- ever dreamed of re-inoculation where the pustule and areola were obtained. The ex- perience, therefore, that any practitioner formerly obtained under the practice of ino- culation, is by no means to be laid aside as useless, in conducting that of vaccination, or enabling him to judge of its merits ; on the contrary, I am seriously inclined to maintain, that if any practitioner has not had that experience, he is incompetent either to conduct, or judge of vaccination, singly, or comparatively.
In conformity then, both with my own experience of the phenomena of inoculation, and vaccination, I contend, that if you have a vesicle, attended with an areola, you may depend upon the production of what- ever effects it is capable of ; and that the erysipelatous inflammation round the ve^ side, forms the principle criterion of its con-
237
stitiitional effect, is farther confirmed, even by Mr Bryce s test of double vaccination,; for surely it cannot be alleged, that it is more decisive of constitutional influence in the secondary vesicle, than in the primary one ; and we have elsewhere shown, that this testis entitled to no more attention than the areola in the first instance, as it never occurs unless the other has previously exist- ed, and therefore the first must be fully as satisfactory, as if the double vaccination had not been employed *.
* Dr AVillan ranks a vesicle without an areola, as an ir- regular appearance, and which will be found not to secure the constitution against small-pox.
Dr Jcnner also says, in a letter to Dr Willan, dated only in February 1806, " The absence of the areola is so rare an occurrence, that I can say nothing decisive upon it. Out of the last 3000 punctures (vaccinations) I have not noticed its being awanting, except in onp instance."
But we must also, here, particularly remark, that if the vesicle could be detected small, or deviating from its com- mon form, and the areola of a particular colour, figure, or trifling extent, in those cases where small-pox succeeded to vaccination, then the cases were pronounced to have been instances of imperfect or local vaccination. We must there- fore conclude, that where the vesicle and areola were charac- teristic, the disease had been constitutionally imparted.
238
But that the areola is to be considered as an unequivocal test, is proved by the cu- rious fact, which inoculators, and vaccina- tors of any experience are well acquainted with ; I mean those cases, where, soon af- ter the introduction of the virus, an exten- sive inflammation follows ; or where, if any accident happens to the inoculated tumor, previous to the formation of a perfect pus- tule, and an areola still succeeds, and con- stitutional symptoms make their appear- ance ; upon reinoculation, or revaccination, with the best attention, we can make no- thing of it.
This naturally leads me to a subject, which is too extensive to discuss here, but which, I think, would not be a very dif- ficult task to prove. What I allude to is, that the constitutional symptoms, in cases of inoculation, do not depend upon the absorption of the virus producing its effects upon the system, by exercising its
239
influence through the medium of the cir- culation. I shall only here observe, that no feverish symptoms, no swelled glands, no startings, are found to follow the most extensive ulcerations, unless attended with symptoms of topical irritation, and inflam- mation. Farther, that all those eflects fol- low from local irritation, without any pus- tule or vesicle whatever ; and in the pro- duction of small-pox, measles, chicken-pox, scarlatina, or cynanche maligna, we have all the cuticular phenomena of these dis- eases, and absorption is far from being con- sidered as the certain medium, by which either these,, or any other contagion, finds its way to exert its effects on the system. I conceive, too, the old doctrines of fermen- tation, and assimilation, to be nearly ex- ploded, and, at all events, to be wholly in- adequate to the satisfactory explanation of the phenomena. The true explanation appears to me to
240
be, that upon the introduction of the virus, it gradually exerts its topical effects, until it produces a pustule, or vesicle, sid generis; that this vesicle, after arriving at a certain length, begins to exert its specific local ef- fect ; and that this is communicated to the constitution, through the medium of the nervous system, which, when it occurs, is immediately accompanied with an areola. Whether this be the true explanation or not, it readily affords a clue to many of the phenomena which attend both vaccination and inoculation, and which, upon the prin- ciple of absorption, cannot be accounted for in a satisfactory manner.
Having thus endeavoured to ascertain, that the phenomena of vaccination itself, afford the best data for determining its constitutional existence, we must now ob- serve, that the proof afforded by the de- scription of these cases is most complete, and satisfactory. Those who were vacci-^
241
iiated by myself, I can take upon me to sa}^, had all the vesicle^ and areola, in their most proper form, although subject to the variety I have already noticed ; andi to the best of my recollection, I never allow- ed any case to pass, without repeated vac- cination, where the areola did not please me, or, in other words, was not extensive;
Those who were vaccinated by the other practitioners, indeed, depend chiefly upon the report of the parents ; but I am not aware, that any solid objection can be made to their evidence *, more especially, when it is considered, that they can have no pro- per motive for deception ; that they may be all competent judges of the existence of a vesicle, or pock, and whether or not it was accompanied, with a circular inflamma- tion; more especially too, when many of
* The vaccinists, it must be observed, admit the eridence of the parents, when it accounts for the failures of vaccina- tion.
242
them had several children successively vac- cinated ; but when these circumstances are corroborated by the account given of the opi- nion, and declaration of the medical gentle- men, the existence of a large and distinct cicatrix being still evident *, the great va- riety of practitioners who conducted the ope- ration, and, above all, the number of cases, and the uniformity in their results, little doubt can remain of their having undergone that form of vaccination, which is capable ' of imparting, whatever antivariolous powers it is possessed of But it may be farther ob- served, that of the cases w^here small-pox recurred, many were in one family, and had been vaccinated both by the same, or by different practitioners at different periods ;
• The appearance of the cicatrix is uniformly made an im- portant circumstance by the vaccinists, in ascertaining the extent of vaccination, and wherever small-pox have occurred, and the cicatrix small, the case is uniformly pronounced im- perfect. We must therefore insist that the proof is vice versa.
it would therefore be surely quite unreason- able to conclude, that they liad been all on- Jy Locally va<x;inated ; and if this is not pos- sible, it then follows, from tlie uniformity of the fcfTects produced, ttiat they must be all considered as cases constitutional vaccina- tion ; for we iiave already endeavoured to shew, that it is impossible to explain the ap- pearances which occur in the history of these cases, by supposing, according to Mr Bryce, that they may iiave been all instances of a mild small-pox, without being influenced fiom the effects of vaccination.
III. — Tliat these cases afford the most convin- cing proof, of the anlivariolous power of Vac- cination, being at best, temporary.
We shall now proceed to examine, how far the proof here adduced can affect the anti variolous efficacy of vaccination ; and, for this purpose, I apprehend it is quite un-
244
necessary to enter into a minute, and detail- ed examination of the cases ; it will not on- ly save time, and trouble, but will also place them in a more distinct, and decisive point of view, to arrange the inferences they afford, under distinct heads ; and I trust they will be found to warrant the following conclusions :
1 . That they afford grounds for conclud- ing, that the antivariolous influence, direct- ly after vaccination, is to be considered as nearly perfect.
2. That in proportion to the distance from the period of vaccination, the antivariolous power is proportionally diminished.
3. That about three years after vaccina- tion, the constitutional influence is so much diminished, as readily to allow the opera- tion of the variolous contagion, but still ex- erting a considerable effect, in mitigating the disease.
245 \
4. That at the distance of five or six years from vaccination, the facihty is so much increased, as hardly to impart any security, and so much diminished in its powers or mitigating the disease, that, at this period, the cases very nearly approach, to the most common form of the distinct disease.
5. That the eruptive fever, and all the other peculiarities of small-pox, increase in severity, and assume the characteristic phe- nomena, according to the foregoing rule, so as to approach to the natural disease.
6. That the period of security, as well as the severity of symptoms, are evidently in- fluenced by the manner in which the conta- gion is applied.
7. That the powers of variolous contagion are evidently increased by the accumulation of individuals, although not attended with small-pox eruptions, and also, in proportion to the number of cases, and extent of erup- tion.
-246
8. They show, in the most irresistible man- ner, that small-pox, either from the natural disease, or from inoculation, are not so liable to recur, or, are not so imperfect a protection against their own future poison, as that which is produced by vaccination, as there was not one instance, where a single individual was in the smallest degree, again affected.
9. They afford grounds for concluding, that cases where the constitution resists the small-pox, although neither inoculated, nor vaccinated, are either not so very uncom- mon, or that they must have previously passed through the disease, in such a slight way, as not to be perceptible.
10. They show there is really no difficul- ty> or great delicacy in conducting vaccina- tion ; for those instances that were vaccinat- ed by the mother, and a farrier, were shown <p be equaHy constitutional from their ef-
247
fects, with those conducted by the whole of the medical practitioners *.
11. They show distinctly, that the pretence of the disease of vaccination, being so little understood at its commencement, is wholly destitute of foundation, and cannot be ad- mitted as an excuse for the occurrence of
small-pox. "
12. They prove distinctly, that, by in- creasing the number of vesicles, you give no additional security to your patient ; and that, although you may thereby increase the appearance of constitutional symptoms, , '^o not render the antivariolous influence of vaccmation more complete.
13. That the cases of re-inoculation, ex- actly correspond in their effects with the in- fluence of the epidemic disease, always mak- ing a nearer approach, both to the external
♦ It is gravely stated by the vaccinists, that a lady in Monmouth has vaccinated 1600, none of which have ever taken the small-pox. She was taught by Dr Jenner.
248
characters of an inoculated pustule, and to the constitutional affection, exactly in pro- portion to the distance they are removed from vaccination.
14. They also distinctly show, that there is a material difference betwixt the powers of the small-pox contagion, exerted in its epidemic form, and when imparted by ino- culation.
15. These cases, and the whole pheno- mena and circumstances of vaccination, shew, that there are just grounds for con- cluding, that a specific action may exist, minusy or negatively, in the constitution ; that therefore it would be improper, in the event of vaccination being found inadequate to maintain its antivariolous character, to re-inoculate those cases which have previ- ously undergone vaccination, before it was capable of producing a distinct constitutional effect.
249
Lastly. That they afford strong grounds for concluding, that this distinct constitu- tional influence cannot be depended upon to take place, sooner than about six years from vaccination.
To these general conclusions, I have to add, that, in many of the cases, the fever, and symptoms of exanthemata, were so se- vere, as to occasion the greatest apprehen- sion of convulsions, or an affection of the brain, and in one instance, a fit actuall^r did occur. This was easily accounted for, from its age ; and the absence of " convulsions, in all the other cases, is to be attributed entirely to their being older, where even in the natural small-pox, they are a very rare occurrence. This case, too, is the only one where the antivariolous influence only ex- tended to a few months ; and the reason of this, as well as her sister not complaining, seemed to me to be owing to being the knee-child, and was carried about by the
250
mother, in her visits to her several neigh- bours, who had all their families affected, and in one house alone, I was informed three children had died.
It is well worthy of particular observa- tion, that amongst all those instances 1 have met with, and I believe, also, nearly all the instances that have hitherto been brought forward, very few cases have occurred where small-pox succeeded to vaccination in the higher, and respectable classes of society. The explanation is obvious ; all the higher ranks of society uniformly availed them- selves either of inoculation, or vaccination; and as they all in general now attend schools, where the whole are on a footing in that respect, and even in their amuse- ments are still amongst themselves, it is impossible that contagion should reach them so readily, either in pubhc or private; but wherever, from necessity, they were placed in different circumstances, then wc
251
find the same result uniformly followed. We may here by the way remark, that this fact also very strongly, nay, indeed, I may may say incontestibly proves, that the others are to be considered as having been perfectly vaccinated ; for it certainly would be nearly madness to contend, that such uniform exemption, can be owing to the process having been properly conducted in the one class, and imperfectly in the other.
This circumstance, too, readily explains, why many practitioners have not met with any cases where small-pox have succeeded vaccination ; as it is well known, that those gentlemen who are at the head of their profession, and in large cities, have very little connection with the lower classes of society ; and this, together with the fact, that these people never think of calling in any medical assistance, even in the most severe cases of small-pox, will easily ac- count for the few cases, that have come to
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the knowledge, of even the hospital vacci* nators; for unless their other practice led them to the spot, where such cases existed, they would never be heard of. Indeed, it may be here observed, from Mr Bryce's own account, that the hospital practice of vaccination is liable to many objections. The vaccinators are in general, entirely at the mercy, and discretion of the lowest class of paupers; they very frequently never set eyes upon the patient after the mere intro- duction of the virus, and are seldom afford- ed more than two, or three opportunities of seeing the arm. Besides, all farther con- nection and correspondence is at an end upon the completion of the process ; they have no farther access to hear of the future security afforded by the practice; and although those gentlemen appear to have vaccinated thousands, for the hundreds of other practitioners, still they do not af- ford reasons in the same proportion, for
2.53
concluding, that their practice, or opinions, are entitled to more weight, and attention.
Before concluding this part of our sub- ject, we must not omit stating, what ap- pears to me a very important, and decisive fact. In the village of East Duddingston, in the month of July last, there were exact- ly twenty-one children who had undergone vaccination, seven of whom, it appears^ from the history of the cases, were influenced by the variolous contagion ; of the four- teen that remained free from any com- plaint, nine had been vaccinated by Mr Gillespie only two or three months before, and of the other five, one was five years old, and had been vaccinated at six months; another three years old, who had been vaccinated at four months; a third two years, and vaccinated at four months old ; a fourth three years, and vaccinated at six months, and the fifth two years, and vac- cinated at five months.
CHAP. VIII.
EXAMINATION HOW FAR THE TESTS, AND SOME OTHER OBJECTIONS, CAN OBVIATE THOSE CASES, AVHERE SMALL-POX HAVE RECURRED AFTER VACCINATION.
We shall now proceed to examine those remaining objections, which the vaccinists contend, are sufficient to counterbalance, and overturn every opposition.
I. — The Tests of Inoculation and Exposure to the Epideinic.
It is contended, in the first place, that the tests of" resisting inoculation, and expo- sure to the variolous contagion^ are so uni-
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form, and so numerous, that they afford the most decisive testimony of the complete antivariolous power of vaccination.
We may however observe, that as near- ly, if not entirely, the whole of the instan- ces where these tests were had recourse to, were only applied a few weeks, or months, after the period of" vaccination, neither their uniformity, nor number, can be allow- ed their full operation in removing every objection, because it is not contended, that vaccination is destitute of all antivariolous power ; on the contrary, it is expressly stat- ed, that it certainly does confer such im- munity to a certain extent, but that it gradually diminishes, and wears out of the constitution. I apprehend it will clearly appear, that when the test of inoculation is either renewed, or deferred for some years, a very contrary appearance takes place, and therefore a very opposite conclusion must be drawn.
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I have elsewhere observed, that if you ino- culate a person who has either undergone small-pox by contagion, or intentionally, at any distance of time from his having passed through the disease, you will not, once in a thousand instances, obtain any thing more than an inflamed, and somewhat elevated point, without the smallest appearance of a pustule, generally beginning to decay by the fourth or fifth day, seldom or never longer than the sixth, and never followed with a scab. On the contrary, if you inoculate a person who has undergone vaccination only a few weeks before, you will almost uniformly obtain a large, highly elevated, and inflamed tumor, having a vesicular point, sometimes distinctly approaching, if not to a pustule, at least to a vesicle, but with no areola, which, after continuing for nine, or ten days, will gradually decay, sel- dom leaving a scab, and never followed, or attended with any constitutional derange-
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ment. W, however, you either fepeat this on the same person, at the distance of a i'ew yeai's, or if you defer inoculation until from two, to five, or six years, after vacci- nation, you will uniformly fnid a consider- able difference produced in the phenomena; the punctured .|3oint will now be found going more or less through the regular progress of the small-pox inoculation ; in ge- neral attended with a small pustule, some- times containing virus, and sometimes with little, or none, and a circular inflammation, sometimes with, and sometimes without constitutional symptoms, not unfrequently with a rash, and sometimes with pustules, or inflamed points.
From the cases contained in this volume, and others to the same effect, which I have not inserted, I have not the smallest appre- hension, that this statement can be contra- dicted by any one, who has had suflicieiit experience of this nature. Indeed, I have
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little hesitation in referring the decision of fhe whole question to this fact, which is al- most within the power of every practition- er to obtain, when I trust it will be distinct- ly found, that in proportion to the extent of the period from vaccination, so will the approach be nearer to the appearance, and effects of perfect inoculation *. But it is also to be observed, that such consequences and appearances are noio acknowledged, both by Dr Jenner, and many other writers on the subject, who at first would not admit of) or.
* In conducting inoculatiom with variolous virus after vac- cination, it would appear, in general, practitioners have been so anxious to communicate the disease, that they introduced the virus in a more severe manner, and in a greater number of places than where it is performed, where no previous vacci- nation has taken place. This method is not only unneces- sary, but prejudicial to the regular progress of the punctured point, and will very frequently end in the disappointment of all concerned. But if the matter is merely introduced by one slight puncture, not much exceeding two-tenths of an inch in depth, and at the same time giving the lancet a hori- zontal direction under the cuticle, it will not only be more certain of proceeding through its regular local progress, but also of producing its constitutional effect.
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at all events, described the appearances upon reinoculation, in a very different man- ner. Mr Bryce, however, seems to consi- der it as a triumphant test of the superior powers of vaccination, that the cases which have come to his knowledge, were followed with, neither eruption, nor other severe symptoms. But here it is to be remarked, that not only the cases contained in this work, but also many others related by dif- ferent practitioners, expressly contradict this assertion, and distinctly shew, that all the symptoms of the most perfect small- pox can be obtained*. But even were it the case, that no such consequences could
* The cases contained in the Medical and Physical Jour- nal for August 1801 clearly prove, that ferer and pustules may be produced by variolous inoculation, only six months after vaccination.
In Dr Willan's account of cases, we also fiud, that out of eight persons inoculated with vaccine virus at different pe- riods, Mr Goldson states, that four had distinct variolous eruptions from inoculation, and four by casual infection. Mr Dunning of Plymouth has also given several cages to the same purpose.
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yet be produced, still it would not afford any great reason to attach greater faith to the practice, because we know perfectly, that inoculation was only recommended, and practised, fi-om its possessing the power of abating every symptom of the disease occurring as an epidemic, and, in many in- stances, rendering them so mild, as hardly to resemble the parent disease : therefore, if vaccination has any antivariolous power whatever, it should certainly be particular- ly evident, when the small-pox virus is ap- plied in the way of inoculation. We may observe still farther, that it has been too readily allowed, that pustules being pro- duced at the inoculated part, afford no ground for concluding, that the constitu- tional influence of vaccination has abated. This, I am by no means prepared to grant, because, neither in inoculation after small- pox, nor even for some tinSfe 'after vacci- nation, or in revaccination itself within
a certain period, we cannot produce the smallest approach to a pustule ov vesicle. Something more is evidently implied in the formation- of the pustule ; and it must,. I think, be concluded, from its being so readily obtained in the one case, and never in the other, a distinct proof is aiforded, that, from the distance of the period of vaccination, some change has taken place in the constitution, more favourable to the production of small-pox.
\{\ from these facts and reasons, we are at liberty to conclude, that the test of ino- culation by no means proves the complete antivariolous powders of vaccination, I ap- prehend that of exposure to the epidemic, is entitled to much less influence and at- tention. We must insist, that the cases be- fore us are to be considered as the most de- cisive evidence, that, in point of fact, small- pox does occur after vaccination ; therefore, although like the test of inoculation, the
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epidemic contagion was resisted directly, or for some time after vaccination, yet still after some interval, it readily reassumes its influence, so that, by the sixth year from vaccination, to produce all its characteristic phenomena to a distressing, and even alarm- ing extent. Fortunately, however, this conclusion does not rest upon the evidence which I have produced ; a prodigious num- ber of cases have been stated, both by vac- cinists and antivaccinists, which put the question beyond all contradiction ; and when we examine the whole which have hither- to been brought forward, we find they are so uniform in their features, and so exactly correspond in all material points, that it is impossible to refuse our assent, that these circumstances cannot be the effect of acci- dent, but must be produced by the partial, and temporary influence of vaccination. That this is really the fact, is also striking- ly corroborated, when we compare the ap-
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pearances which we have seen take place from reinoculation, with the phenomena produced by the application of variolous contagion ; for we uniformly find, that they bear an exact proportion to their effects upon the system, where it has not previous- ly undergone the variolous disease; the epidemic contagion always producing a more severe disease, than what takes place from introducing the variolous virus, by ino- culation. But farther, the uniformity of the extent of their influence upon the sys- tem, so exactly corresponds with the distance from vaccination, that a very decisive proof is afforded, not only that vaccination had ex- erted its effects upon the system, but that it was actually daily diminishing.
The assertion, that although Dr Jenner, and his nephew, have vaccinated upwards of five thousand, not one instance has occurred which has been succeeded by small-pox, is, in my opinion, entitled to but
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littles weight in determining- this question^. Before this ean have any iiafluence, the Doctor, aad his relation nuLSt shevf, that iq point of fact,, there exist such circumstances in conducting vaccination, that few, or none but himself, and his relatioa, can be a judge of) and sufficient grounds made out, for a complete change in the whole circumstan- ces of the affection, so as to cancel the ef- fect of all those cases, principles, and in- structions which were first given by himself on the subject. It is impossible, too, to at- tach implicit credit to these assertions ; for, independent of both the Doctor and hig nephew being prmcipals in the cause, and fully committed to the public for the advan- tages of their discovery, the description first given by the Doctor, of the appearances that took place upon reinoculation, were wholly incorrect, and is even now, contradicted by himself But farther, such an assertion is not to be credited, when it is considered.
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that it comes from a quarter, that has not hesitated to saj^^, that all the cases hitherto brought forward, must be either chickai-pox or bugTbites *. In these obser\ ations, we do not mean to charge the Doctor with wil* ful misrepresentation; on the contrary, we are ready to allow him the greatest merit for his diligence, and even accuracy, in his researches upon tliis business, and that no individual perhaps could have resisted, or indeed, w^ould have been warranted in re- sisting-, such evidence as the subject admit- ted of; but certainly we do mean to assert, that these circumstances clearly point out, a strong prejudice, and partiality, in favour of his discovery, and a blindness, and en- mity to every fact, which can miUtate against it.
* An assertion to which the testimony of the College of Physicians in London, Dr Willan, Dr Adams, and many other respectable authorities, are m direct opposition.
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II. — Analogy. The advocates of vaccination also con- tend, that analogy affords no encourage- ment to the opinion of the temporary in- fluence of vaccination, but positively sup- ports the idea, that after such an impression is made upon the system, it WiW neither di- minish, nor wear out.
I apprehend, however, on the contrary, there are the strongest grounds for con- cluding, that analogy not only gives no countenance to such an opinion, but ex- pressly supports the idea of a temporary and partial influence, and, at all events, can afford but little refuge from the present pressure of facts, although the Royal Col- lege of Physicians in London have given it their sanction.
We must first observe, that certainly the Royal College forgot, they had previously admitted, without any reserve, that nothmg analogous existed in nature ; we, therefore.
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cannot exactly see the propriety of extend- ing the benefits of this general rule, to the phenomena of that practice. We might, perhaps, be able readily to understand, how vaccination, if a specific disease, might re- cur only once in our lives, like many of the class of exanthemata ; but how we are to allow, or to draw a conclusive proof from this circumstance, that the existence of one disease, is capable of preventing another, however opposite, is what we have no evi- dence of We see that measles, small-pox, chicken-pox, aixl hooping-cough, readily prevent the recurrence of themselves ; but we do not find that they prevent each o- ther; and, therefore, unless it could be shewn, that the cow-pox, and small-pox are one and the same disease, no such power can possibly be granted. But farther, it is to be observed, that all those diseases which the constitution is positively exempted from a repetition of, so as safely to constitute a
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general rule, carry the most convincing, and decisive proof of their existence ; and, indeed, produce a series of symptoms, by far the most severe, and distressing, that are to be met with, in the whole of the diseases to which the human body is liable. In this respect, vaccination is totally without all pretensions. It really has no other phenor mena, but what belongs to the vesicle ; and, in these respects, has a striking resemblance to what we see produced, by the introducr tion of many other fluids *.
But again, there are many circumstan- ces which distinctly prove, that, after the system has been once constitutionally af- fected, it is neither so apt to be influen- ced by a repetition of the same cause, nor, if it should recur, to the same severity
* This is clearly demonstrated from the difference we have already seen in successive inpculations, betwixt the effect of the vaccine fluid, and variolous virus ; for, in the one, you can seldom, or never, reproduce a characteristic pustule, while in vaccination, it is generally acknowledged, that you may have the vaccine vesicle, either casually, or otherwise, repeatedly.
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and extent. The history and phenomena of scarlatina, cynanche mahgna, pestes, dy- s^teria, yellow-fever, and other diseases of climate, and, I believe, we may add every fe- ver produced from contagion, clearly shew, that they by no means recur, whenever the individual is again exposed to the same cause, but give, in all cases, a temporary se- curity, and, in general, render a second at- tack comparatively mild. Indeed, there seems to be a general principle in the laws of the human oeconomy, that, after it has been influenced by any power, it is, for some time, exempted not only from a repeti- tion of its effects, but also from those of any other cause ; and the distance seems, in ge- neral, to bear a proportion to the severi- ty, and extent of the power previously ex- erted. This, too, is farther confirmed by the well-known fact, that, in all the cases of a second attack of any of the exanthemata, they are uniformly the consequence of
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being exposed to a long continued applica- tion, and an increased severity in the powers of the epidemic.
We are here again naturally led to in- quire, if there can possibly be any grounds for supposing that casual vaccination posses- ses any greater powers of influencing the system, than that by inoculation. In our inquiries upon this subject, we have already seen, that Dr Jenner, and all his followers, contend for no such difference, and allow them equally to posses the antivariolous quality. Indeed, the Doctor's history of the discovery, seems clearly to shew that they are exactly the same, for there, the same contradiction of the phenomena, and the same occurrence of small-pox takes place ; but it is to be particularly observed, that several cases are given where they resisted inoculation, and exposure to the epidemic, even twenty and thirty years after having ithe cow-pox. With regard to this fact, it is
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to be observed, that such cases were certain- ly rare, and I must suppose, anxiously in- quired after, by Dr Jenner, to satisfy himself of the truth of his ideas. Also, it is to b^re- marked,that before a person can be fit for the office of a milker, he must at least, be sixteen or eighteen years of age, and that thereby, an opportunity has been afforded, for -being in- fected with small-pox, which he might have caught in a very mild way, and have been im- perceptible to the mother * ; or they might have been those instances of peculiarities of constitution, which we frequently meet with, resisting the small-pox, and of which, there are one or two in the present volume ; for cer- tainly it is not supposing too much, that per- haps a hundred of such description, might, upon adihgent inquiry, be found in Xhecounty of Glocester. The Doctor's instances, of
* Here the Doctor's cases are faulty, as they do not notice whether or not the small-pox had been subsequently in the family, or that an opportunity had been afforded for commu- aicating the disease.
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this description, to the best of ray recollec- tion, did not exceed a dozen, where he submitted them to the test of inoculation ; and even,all the well authenticated instances be could collect, did not exceed a hun- dred *, where the casual disease resisted small-pox ; notwithstanding, the cow-pox is allowed to be a very frequent occurrence in that county. In addition to all this, we may observe, that there is neither difficulty, nor improbability, in such persons having" their constitutions constantly charged with the antivariolous power of vaccination ; for, as according to the Doctor, they may take the disease in its most characteristic form, over and over again ; therefore, by continu- ing exposed to be infected, they may be readily found in a state of resistance to the variolous influence, and still its powers onli/ temporary.
* I should have thought, that these were rather a scanty number, to build such a fabric upon ; especially, too, when so much was at stake.
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We cannot dismiss this part of our sub- ject, without noticing the arbitrary opinion of Mr Moore ; he says, « he wbuld more easily believe that an able physician should commit a mistake, or disguise one, than that such an incongruity should occur, as small-pox succeeding to perfect vaccination." This gentleman was the author of a tract, entitled, " A Reply to the Antivaccinists," where, amongst many other interesting re- marks, we meet with some valuable observa- tions on the nature of medical evidence, with which we entirely coincide; but it affords an- other proof of the melancholy effect of sys- tem, that the very individual who can make such observations^ shall avowedly stand forth a desperate instance of their truth and justice^ and candidly confess, that he will reject every proof, however much the appearance of. truth it may possess. To such a deter- mined dogmatist, Ave have, therefore, no- thing to offer that can possibly be expected
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to have any influence ; but nevertheless, we do not despair of seeing him under the ne- cessity of confessing the justness of his re- marks, as apphcable to himself
III. — That the number of Cases where Small- ' pox have succeeded Vaccination, are not more numerous than those, xvhere Small-pox have recurred a second time.
This assertion, I apprehend, will appear totally incorrect. It has been elsewhere noticed, that all the instances the vaccinists, with the most diligent inquiry, have be^n able to collect, have not much exceeded twenty cases; and this too, although the natural small-pox have been known in this country, for nearly a thousand years, and inoculation almost a century, and many of these cases too, accompanied only with such evidence, as the vaccinists would either readily reject, or.contrive some means ot de- feating, were it brought forward in support
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I of cases where small-pox have occurred after vaccination. When we compare this statement with those which have already made their appearance, where instances of small-pox have occurred after vaccination, we shall have little room lor doubt 'upon the question. In the first I place, it is to be remarked, that vaccination has only existed, to any extent, about eight •years ; and that, although a prodigious number have gone through the disease, yet ! still it bears no comparison with the extent I of the natural small-pox, and the practice of i inoculation. The difference of the length I of the periods, too, constitutes a material Ipoint; for in the former, ample time has Ibeen allowed for the occurrence of every •cireumstance which could possibly be fa- wourable for the repetition of the disease ; whereas, in the other, time has hardly been s^fforded for proving its perfect antivariolous {power, in any other way, than by imme-
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diate inoculation, and exposure to the epide- mic, which, we have already shewn, are not to be depended upon. It is well known, too, that small-pox only occurs as an epide- mic, every three or four years, and there- fore, as it is proved that vaccination, in a great measure, shields the constitution for an equal period, time has only been afford- ed to put its antivariolous powers once to the test.
When to these material considerations we add, that the Royal College of Physicians, and the Royal Jennerian Society, in London, admit, that cases of small-pox have occurred, where sufficient proof h as existed of the most perfect vaccination, and that the report of the Royal College of Surgeons allows of fifty- six, resting upon the best authority.
To these statements, of such respectable public bodies, we have to add those cases given by Drs Jenner, Willan Ring, and
* In DrWiUau's publication alone, he has collected, from
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other professed advocates of the practice ; those brought forward by the opposers of vaccination ; those stated by Dr Adams, (who, I may here observe, seems to have conducted himself in this business with much circumspection) ; the cases related by Mr Bryce, and those which are now before us; such an accumulation of proof is afforded, as not only to abolish all parallel betwixt the two diseases in this re- spect, but to point ,out, in the most striking manner, the ttmporary and feehk protection afforded by vaccination, against variolous contagion.
It is here not possible to avoid the re- different authorities, upwards of sixty cases, where small-poj? occurred after vaccination, in the natural form, besides the terms some and several, which different practitioners heard of. From all which, and the cases occurring from inoculat. ing with variolous virus, the Doctor is obliged to admit, that they were cases of small-pox after vaccination, but endea- vours to render them of little consequence, and save the cre- dit of the vaccine practice, by allowing an imperfect and mo- dified action of the yaccine virus.
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mark, that there are evidence sufficient to create the strongest suspicion of the most unwarrantable, and uncandid suppression of facts, and that every thing has either been kept out of the way, or mutilated, misrepre- sented, and depreciated, which could possi- bly lead to any conclusion, injurious to vac- cination. In my humble opinion, it would certainly have been more consistent with the character of the Royal College of Sur- geons, and the Royal Jennerian Society, as well as with the attainment of truth, to have published the whole of the cases in their pos- session, or, at least, mentioned their total amount, and characterized those circum- stances, which, in their opinion, rendered them suspicious and doubtful ; thereby af- fording a full and fair opportunity for the investigation of the subject.
If I am not much mistaken, it will soon appear,' that this misguided zeal has been highly injurious to the interests of societ)^
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and is more reprehensible than the most violent opposition of its most determined op- ponents. I am also convinced, from what has passed under my own observation, for these last three or four years, that we have been all guilty of rejecting evidence that deserved more attention, in consequence of the strong prepossessions which existed, from
^ the very persuasive proof of its resisting inoculation, and exposure to the epidemic, and from our judgment being goaded, and
, overpowered, with the positive and arbitrary opinions of its abettors. I am now perfect- ly satisfied, from my mind being under the influence of prejudice, and blind to the im- pression of the fairest evidence, that the last time the small-pox were prevalent, I reject- ed, and explained away many cases, which were entitled to the most serious attention, and showed myself as violejit, and unreason- able a partisan as any of my brethren, in propagating a practice, which I have now
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but little dobut, we must, ere long, surren- der at discretion. I cannot but believe, that the same facts, and observations, must have occurred to most of the profession who are engaged in an extensive practice. They have, I am afraid, like myself, shut their eyes against the fairest proof, and en- deavoured to resist, when no longer ten- able. I hope, and trust, however, they will no more be influenced, and prejudiced by what is too often considered, superior au- thority ; but, being fully aware of the great importance of the subject, to the tenderest feelings of the community, they will speedi- ly, and candidly, bring forward every case, and fact, which can possibly bear upon the subject, and either rescue the practice from doubt and contradiction, or produce its com- plete annihilation.
IV. It only remains for us to notice the last, and most feeble shift to defend the practice, i, e. that if such cases do occur, they are al-
2B1
xmi/s mild ; and, on the contrary, where sjuall^ pox take place a second time, they are akvays severe *. It seems hardly necessary to op- pose such a defence. We have already seen, that, according to the distance of time from vaccination and the concentrated state of the epidemic, the disease approaches more and more, to the common form of distinct small- pox, and, in many cases, to such an ex- tent of pustules, as not to be destitute of danger.
If this was the case when only a few were six years vaccinated, what may not be the consequence at the distance of twenty, or thirty? The idea is dreadful, and distressing, and requires the most speedy attention, and relief; for it is but fair to conclude, that they may be liable
* It is re<T,lly curious to observe the anxiety, and eager- ness -with which the vaccinists catch at CTcry little relief the practice of inoculation affords. How far they have succeed- ed in such appeals, I may safely leave to the judgment of every practitioner.
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to the most severe, and distressing form of the disease, and exposed to its Avorst termi- nation. I apprehend, too, that the state- ment of such recurrence of smali-pox being always severe, is by no means evident, for the deaths do not even amount to the average of the most comiAon form of the epidemic, and both their recurrence, and severity seem, from their history, entirely to depend upon the extent, and virulence of the contagion ; and, at all events, the in- stances are confessedly so rare, that it is impossible to found upon them, any gene- ral conclusions.
We cannot conclude our present inquiry,- without noticing that very* able, and inge- nious article on. this subject, contained in the seventeenth number of the Edinburgh Review. In addition to what we have al- • ready said, as obviating many of the argu- ments there brought forward, w^e have to observe, that the objection which is there
started, of the same opposition being made to the introduction of inoculation, cannot here apply. In the case of inoculation, it immediately arose upon the commence- ment of the practice, and was entirely pro- duced from the theoretical opinions of me- dical men, concerning the nature of inocu- lation itself, or from prejudices produced by religion, and the novelty of the practice. Here, however, the opposition still conti- nues, although a number of years have elapsed, sufficient to have elucidated, and confirmed the discovery, and the disease is to be obviated by an expedient' totally dif- ferent, and which has no analogy in nature. We have also a total change of its prin- ciples, and effects, since its introduction; a more violent contradiction,'* land flagrant opposition in. the- opihibti of the most zea- lous abettors of the practice, and, above all, a daily increase of cases, where small-pox Ijiave su'cceeded to vaccination. We must
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also take the liberty to remark, that the article is written by a gentleman, professedly not of the medical profession, therefore he could not, from his own experience, detect what was false, ascertain what was doubtful, or correct what was erroneous; and his judgment depended entirely upon what was brought forward by both parties. There can be no doubt, that his conclusions are just, if his premises were correct ; but I hope, as he candidly confesses, that the practice must stand, or fall, by the number of instances, where it has failed in resisting small-pox, he will think the proof here brought forward, sufficient to arrest the attention, and damp the ardour of the most (determined vaccinist.
CHAP. IX.
CONCLUSION.
It now only remains we should notice the assertion, that the complete annihila- tion of small-pox, must be the consequence of the universal adoption of the practice of vaccination.
It must be confessed, the accounts from many parts of Europe, nay, indeed, from all quarters of the world, give countenance to this opinion, and distinctly shew, that hitherto, wherever vaccination has been in- troduced, the small-pox have uniformly di- minished in severity, and extent, so as, in many parts, almost totally to banish the va- riolous affection.
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Although I am ready to allow these ac- counts to be so far agreeable, and evident- ly demonstrating the practice to possess an antivariolous power, I still contend those flattering testimonials may all be obtained, and yet the antivariolous powers of vacci- nation to be only temporary *.
After what has been already offered, I apprehend it is quite superfluous to enlarge much upon this part of the subject. It ap- pears to me impossible to conceive, that we can, or ought, to place the smallest con- fidence in any power, being able to extir- pate, or extinguish a disease, which it has not influence to prevent. We may, how-
* Here we may, by the way, remark, that this universality of the effects of vaccination, in subduing the variolous con- tagion upon the Continent, affords one of the most decisive, and irresistible proofs, that there is neither mystery, difficul- ty, nor uncertainty in conducting the practice; for it sure, ly would be most unreasonable to contend, that the rest of Europe, possesses members in the profession, of superior abilities, or, that they have better opportunities of being sup- plied with virus.
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ever, observe, that in all, or most of those situations, from whence such favourable accounts have been received, the practice may be said, in point of experience, to be only in its infancy, and, at all events, is quite incompetent to decide this question, as it does not exceed four or five years, since its first introduction. Sufficient lime, therefore, has not been afforded^ to put its permanent powers to the test; for we have already seen, -that in general, vaccination secures the constitution from the variolous "influence, to the extent of three, or four years ; and we also know% that small-pox only make their appearance, as an epide- mic, at the interval of some years. It is also to be particularly remarked, that the •same consequences were found to result from the praptice, for the first few years in this country; but in London, and other large cities, when vaccination was first in- troduced, and practised to a great extent.
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small-pox have returned with increased Se- verity.
But it is to be farther observed, that the great number of instances where small-pox have occurred after vaccination, have been for some years past so frequent, as nearly to check the further progress of the disco- very, and, in every situation in this coun- try, where the vaccine practice had been employed to any extent, and the inhabi- tants numerous, an increase in the number of cases have regularly occurred upon every appearance of the epidemic small-pox. I. can also with truth declare, that the cases given in the present volume, do not exceed one half of what 1 have met with ; many I rejected, and explained away some years ago ; others I received information of, too late for sufficiently authenticating the cases, and several I have not now inserted, as they appeared unnecessary and superfluous. When, to these circumstances, which, I dare
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say, are ajDplicable to every practitioner, we shall add the general mildness of" such cases ; the accidental manner in which we were iTiade acquainted with many of them ; and that parents of the lower classes of so- ciety, do not consult the medical profession, even in severe cases of small-pox, it is evi- dent, many more must have either passed unobserved, or have been considered as un- deserving of attention. Indeed, I do think I am below the truth, when I say, that in this quarter alone, upwards of two hundred such instances must have already occurred*.
If this has been the consequence of the appearance of the epidemic small-pox in this neighbourhood, it is but fair to conclude, that it must also have been the case, where- ever the disease has made its appearance, more especially, as such cases have already occurred, in every situation, where vaccina-
* In London, the occurrence of small-pox after vaccina- tion have been for some years so frequent, as to check the farther progress of the discovery in the city and environs.
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tibn had been practised to any extent, and that they must either h ive escaped observa- tion from the causes I have already stated,, have been anxiously suppressed, or consider- ed, from their mildness, as forming no great objection to the practice. Within these few weeks, however, I have received such ac- counts from Edinburgh, Dalkeith, Had- dington, Dunbar, Berwick, Alnwick, and several other places * where the small-pox
* I have, within these few days, had an opportunity fo peruse a letter from Dunkeld, from one who lost a son eleven years of age, from small-pox occurring about six years after vaccination. It stated, that the small-pox had been raging there for some months ; that twenty-six cases had already occurred, Avhere, small-pox succeeded to vaccination, three of whom died ; and that six had fallen a sacrifice to the epi- demic, where no vaccination had been employed. I may here also observe, that I am acquainted with t;wo or three cases, where the occurrence of small-pox have been attended with fatal effects. I must, however, observe, that, in all of them, some objectioiis seem to have been started by the prac- titioners, but there appeared not a little confusion about the important point, whether or not these objections were only made, after the occurrence of the small-pox. The history of vaccination, also, affords many instances of deaths occurring under such circumstances, and shesv the pressing necessity for adopting decisive measures, either to acquire some definite ideas of the practice, or to relinquish it entirely.
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have been, or are still prevalent, of the frequent occurrence of such cases, that it is not going- too far to say, that many thousands of instances must have already occurred in this island. When, to all this, we shall add, our total ignorance of the nature and source of the snjall-pox contagion ; its viru- lence, its activity, its ancient, extensive, and dreadful effects; it is impossible to sup- pose for a moment, that any power which only possesses the property of an imperfect, and temporary antidote, can be trusted to, for subduing, and extinguishing, such a dan- gerous, and universal disease.
I have now brought to a conclusion, those observations, which the state of the practice of vaccination, together with the cases here brought forward, naturally suggested to my apprehension. It is, perhaps, too much to assert, that they are decisive and convin- cing; but certainly I may be allowed to say, they not only seem entitled to attentiofl, but
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are sufficient to shake our confidence in the efficacy of the practice. They seem also to prove, that the whole subject requires the most serious investigation, and that the powers of vaccination are feeble and tem- porary.
If this is the result of our inquiry, it very naturally occurs to be demanded, what is the most prudent conduct to follow, under such circumstances ? Shall we continue to carry on, and advise the practice of vaccina- tion, at all hazards ? or shall we return to the old practice of inoculation ?
I apprehend, it is impossible with a safe conscience, or with a mind alive to all the disasters and distress which may ensue, to disregard the danger which the dearest con- cerns of the pubUc are exposed to; and it must bring indelible disgrace upon the whole medical profession, to be detected and ex- posed, only by the most glaring confusion, and the most disastrous facts.
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We have shewn, from an attentive exami- nation of the history of the affection, that its source is involved in mystery ; that the ori- gin of the practice is loaded with contradic- tion ; that it is incapable of influencing the system, in a regular or positive manner; that many of the phenomena of the disease, resemble those produced from matter, pos- sessing no specific influence ; that in gene- ral its effects, so far as they can be observ- ed, are merely local ; that no one certain criterion exists, of the attainment of consti- tutional vaccination ; in short, there is not one circumstance belonging to the subject, void of confusion, uncertaintj^ and contra- diction. But when, to this terrific, and dis- gusting chaos, we add, the positive proof of the frequent and regular occurrence of small- pox, succeeding to vaccination, I appre- hend, little room is left for hesitation. It would surely be most unreasonable to ex- pect, that the public should continue their
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patronage, under such glaring inconsistency, and such positive testimony of" its defects. It would certainly be most absurd to sup- pose, that they would still follow a practice, where they must be assured, their tenderest concerns must be exposed to sickness and distress, however safe the result might be ; but it would undoubtedly be downright madness, to imagine they will condescend to encourage it, when it appears they may un- dergo the disease, in its most distressing and dangerous form *. In the present state of
* As an argument in favour of continuing to adopt the practice of vaccination, in preference to inoculation, Dr Willan supposes, that only one case in eight hundred has oc. curred, where small-pox have succeeded to vaccination, in- cluding mistakes, negligences, and mistatements, and there- fore puts the question, that if one in a thousand should take the small-pox, would the utility of vaccination be invalidat- ed ? and concludes, surely not. Were this proportion even the fact, it would be perhaps sufficient to damp our ardour, in propagating the disease; for although this occurrence should be as rare as deaths, from the practice of inoculation, jet, as the practice of vaccination is only in its infancy, and time has not elapsed, to fix, neither the proportion, nor se-
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things, I apprehend, inoculation is both what we should recommend, and they should adopt. It is a practice, possessing the most satisfactory characters ; it is pro- pagated from the same disease it means to combat; produces an affection in all respects
verity of the cases, many would hesitate in subjecting them- selves to such a precarious security, and would rather sub- mit to adopt a practice, although attended with a positive risk, than exist in a state of apprehension.
But, from the statements contained in this work, and more especially, respecting the village of Duddingston, it appears, that this is out of all proportion ; for there, the cases where small-pox succeeded vaccination, were as one in three. AV"e have also seen, that in the parish of Inreresk, upon a mo- derate calculation, two hundred cases have also occurred. Supposing therefore (which I believe to be near the truth,) that 2500 have been vaccinated, it will give upwards of six in the hundred. But as we have seen, that those cases where small-pox have occurred, are, in general, at the distance of four years from vaccination, we must therefore reduce the number vaccinated to one half, which will then make the number nearly thirteen in a hundred, or about one in eight. If we apply this rule to the Duddingston cases, and thus cut oflf those who were vaccinated by Mr Gillespie, we will then find, that nearly the whole who, from the period of vaccina, tion, were in a state to be influenced by the variolous conta- gion, underwent the small-pox.
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similar ; its progress and effects are certain, and uniform ; it is in general, mild and safe, and its consequences are complete, and sa- tisfactory.
From the brief view we have already presented of the state of inoculation, previ- ous to -the introduction of vaccination, it appeared, that although the practice was exposed to the fancy and whim of indivi- duals, and that man^^ circumstances were omitted in conducting the process, which were entitled to the greatest attention, yet still, only one in five hundred fell a sacrifice to, or was otherwise injured from the prac- tice. If this was the state of inoculation, with all its disadvantages, what have we not reason to expect, if the same attention and patronage were bestowed, as have been af- forded to the practice of vaccination, and every improvement made, which the sub- ject is capable of I have not the smallest doubt, that the number of deaths might be
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made, either entirely to disappear, or, at all events, to occur so rarely, as to form no ob- jection to the practice ; but also, a more de- cisive and effectual method would be ob- tained, of eradicating, and destroying, the baneful effects of the epidemic disease.
It is impossible that the objection, of inoculation always affording a constant source of infection, can be allowed any weight. This ought only to be considered as a spur for rendering the practice univer- sal ; for it surely can neither be required, nor expected, that any individual should continue to adopt a practice, merely be- cause it may at present prevent the spread- ing of small-pox, without being satisfied, that it will either effectualli/ secure them- selves, or ultimately subdue the variolous contagion. It might, with equal justice, be expected, that we should deny ourselves every opportunity of improvement, or re- fhse to take advantage of favourable events.
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merely because they either are not perceiv- ed, or are disregarded by others.
There still remains one veiy important, and highly interesting point, upon which it may be necessary to make a few observa- tions. Those who have hitherto adopted the practice of vaccination, miist certainly be placed in a most painful, ami distressing situation, and feel extremely anxious to know, what is the best plan for satisfying themselves of the security, and ultimate safety of those, who have submitted to vac-r cination.
From the view we have taken of the sub- ject, and the facts we have submitted, I ap- prehend, until the whole undergo a tho- rough investigation, few practitioners will be so Ijold as to advise, and few individuals will be so blind as to place, an indiscriminate, and unlimited confidence in its effects. We would, therefore, recommend, that not only all those who have been simply vaccinated.
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but also, all who were submitted to the tests of inoculation, and exposure to the epi- demic at an early period, should undergo a second inoculation with variolous virus.
The reasons for including those who were formerly either inoculated, or exposed to the variolous contagion at an early period, have been already explained ; but it may be here observed, that, as these tests were employed at a time when they neither did, nor, it ap- pears, could be expected to produce any constitutional influence, and when inocu- lation was merely attended with an inflam- ed point, or tumor, without being accom- panied either with an areola, or constitution^ al derangement, these, tests cannot be con- sidered as giving any farther security, and are merely a proof of the antivariolous in- fluence of vaccination having been, at the time exerted. But when we see, that, upon inoculation being employed at a greater distance from the period of vaccination, it
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gradually assumes both the appearance, and effects, of the primary variolous inoculated pustule, in exact proportion to the distance from vaccination, and that these phenome- na also exactly correspond, comparativeljr, with the influence of the variolous epide- mic, we must conclude, that some change has taken place, favourable to the produc- tion of small-pox. We have also seen, that this period of security seems, in general, on- ly to extend to the distance of three or four years after vaccination, if the individual is exposed to the epidemic contagion ; but if the infection is introduced in the form of inoculation, it in general requires a distance, at least, of five years from vaccination, be- fore you can produce either an areola, or constitutional symptoms.
Although, for the reasons already given, I consider the areola as a decisive test of a constitutional effect, yet, as we have strong reasons for supposing, that a specific action
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may exist viinus in the constitution, I would rather recommend waiting until a distinct constitutional effect can be obtained, which, I am inclined to think, will be found pretty- uniformly to follow, about the sixth year from vaccination *.
Although I have not hitherto met with any cases where small-pox have occurred, after undergoing the test of inoculation, yet I am not the less satisfied of the truth of this opinion ; because, as I have already observed, hardly one instance has yet oc- curred, where small-pox have succeeded to vaccination, in the higher and respectable classes of society, and it was chiefly amongst these, that the test of inoculation was sub- mitted to ; and also, from the appearances
* At this period, there seems every reason to conclude, that yoM will not only obtain the areola, and satisfactory constitutional symptoms, from repeating the inoculation %vitl» variolous virus, biit also, that still the cflect of vaccination exists to such a degree, as to give the certainty f)f a sofa result.
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which have taken place in such as have been again submitted to the test of inocula- tion, at the distance of two or three years, after having undergone the first test, when we find pustules and areolse can be produ- ced, although they had not been obtained in the first instance*
« Dr Stanger, physician to the Foundling Hospital, states to Dr "W^illan, that " thirty-five children, vaccinated between the 30th March 1801 and the end of May 1802, were inocu- lated with recent variolous matter, on the 9th of August 1802. lu most of these cases, the puncture presently heal- ed ; in some, slight inflamation was produced ; and in three or four of the cases, there appeared a small accuminated pus- tule, which, after some days, was succeeded by a slight scab, no constitutional disorder having intervened.
" In November ISO*, twenty-one of the children vaccinat- ed in 1801, and afterwards variolated in 1802, were a second time inoculated with matter taken from a child, labouring un- der the natural small-pox. The result of this trial, made three years and a half after vaccination, confirmed its preven- tative power. The only effects produced, were slight inflam- mation, produced about the puncture in some cases, and in a feio others, a small local pustule, which soon disappeared."
Now, I apprehend, from this description, although a very imperfect one, it clearly appears, that what I have elsewhere contended for, is strikingly corroborated ; for in those ino- culations, which included only periods of some months, to
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Indeed, it is in these circles of society, that the great danger of the practice seems to he ; for, as I have elsewhere observed.
that of twelve, only a very trifling effect, such as I have al- ready described, was produced ; but when it came to be re- peated, at the distance of two or three years, not only did the previous inoculation afford no additional obstruction to the progress of the second inoculation, but now a greater in- flammation, and even pustules were produced ; distinctly shewing, that the immunity from small-pox was much wea- kened, by the increased distance from vaccination. But there is a case, which occurred to a Mr Kendrick, a practi- tioner at Warrington, which appears to me to decide this point. — " S. C. aged nine months, was vaccinated in February 1800. Mr Kendrick saw the child on the ninth day. The vesicle was of the usual form, depressed in the centre, and elevated at the circumference. The areola was fully formed, and the mother thought the child appeared a little feverish during tiie night. On the 10th of June following, this child was inoculated with variolous virus. On the fourth day, the arm was a little inflamed round the puncture ; fifth day, the inflammation a little increased ; sixth, the inflammation/still increasing, and a small quantity of pus formed ; seventh day, -inflammation decreasing ; ninth day, inflammation nearly gone. No fever or eruption ever appeared.- On the Janu- ary following, the small-pox raged, with great violence, in that part of the town where the child lived, and she was then repeatedly, and fully exposed to the infection. On the 14th «f that mouth, Mr Kendrick was requested to see the child,
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they are more excluded from exposure to the epidemic, by which they may avoid its effects, while the antivariolous power is yet capable of mitigating the disease, and in their progress through life, may be exposed to, and infected with the variolous contagion, when all the influence of vaccination is ex- hausted, and left completely at the mercy of the epidemic.
Before closing the subject, we shall sub- join a few quotations from different autho- rities, which will distinctly shew the state of the practice, even in the opinion of its most zealous abettors.
The following are extracts from a letter of Dr Jenner's to Dr Willan, dated only on the 23d February 1806 :
in consequence of an eruption having appeared upon it. He was informed, tliat, on the ninth and tenth, the child had been extremely feverish, and that, on the evening of the tenth, an eruption had appeared on different parts of the body, resem- bling the distinct small.pox. The pustules had continued to increase, and were then increasing, and did not fully matu- rate until the eighteenth."
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In answer to the question from Dr Wil* Ian, — what are the changes produced in the vesicle, when a person is affected with the shingles, vesicular ring-worm, or impe- tigo * ? Dr Jenner observes, " they usually produce a striking deviation from the cha- racter of the vaccine pustule, at some pe- riod or another of its progress, but more frequently in its early than in its declining stages ; indeed, it is commonly perceptible in a dai/ or two after inoculation (vaccina- tion). It would be difficult, perhaps im- possible, without the aid of drawings, to give a correct description of the varieties, which an herpetic state of the skin is ca-
* Dr Willan obserrcs, that " the cutaneous diseases which sometimes impede the formation of the genuine vaccine re- side, are herpes, (including the shingles and vesicular ring* worn.), the dry and humid tetter, and the lichen, but espe- cially ?he porrigo (or tinea), comprising the varieties de- nominated crusta lactea, area, achores, and fari, all of which are contagious. To these perhaps should be added, the itch and prurigo."
U
t
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pable of producing, from those trifling devi- ations which prove no impediment to the vaccine security, up to that point of im- perfection in the pustule, which affords no security at all. In saying no security at all, perhaps I commit an error ; for it strikes me, that the constitution loses its susceptibi- lity of small-pox contagion, and its capability of producing the disease in its perfect and ordinary state, in proportion to the degree of perfection, which the vaccine pustule has put on in its progress ; and that the small- pox, if taken subsequently, is modified ac- cordingly. When no deviation takes place in the ordinary course of the vaccine pus- tules, or when it is inconsiderable, the her- petic blotches or vesicles, of whatever kind they may be, often assume (sometimes as early as the third or fourth day * after the
* It would be easy to shew, that this is not only quite contrary to general experience on the subject, either of vac cination, or inoculation, but is also completely impossible to be effected, by the vaccine puncture, at the period mentioned.
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rnsertion of the vaccine fluid) a new cha- racter, not unlike the vaccine, and keeping pace, in their progress, with the pustules on the arm, die away with them, leaving the skin smooth.
" What appearances the variolated arm puts on when the skin is affected with irri- tative eruptions, I have not an opportunity of ascertaining.
" That the small-pox inoculation, like the cow-pox, sometimes fails when the skin is at the same time diseased, I have abun- dant facts before me to prove *.
* The two last paragraphs follow each other in the let. ter almost in close succession, and to me appear in down- right opposition to each other, although perhaps Dr Jenner may be able to reconcile them. I must however remark, that It betrays an anxiety to support vaccination at the expencc of inoculation, and indeed we have seen, that wherever vac- cination appeared deficient, relief was uniformly sought from comparing it with inoculation. With what truth, we have ■already endeavoured to shew in many instances, but here I *ipprehend there are less grounds than ever; and it clearly •pamts out the anxiety and feelings of the vaccinists them- selves on the subject. Every practitioner of even moderate
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" I have often been astonished at seeing how small, and apparently how trijiing, a local affection of any part of the skin, is capable of occasioning derangements in its action in parts at a distance, although its disordered state be of such a nature, as not to be discernible hy the eye. For example ;
experience, either in inoculation, or the epidemic disease of sraall.pox, must know, that no such obstacle or modification is opposed by any cutaneous disease whatever ; that, on the contrary, these diseased states of the surface are not an un- common cause, of a severe fever, and numerous eruption ; that wherever those cutaneous affections exist, there, in general, the number of small-pox are most numerous. For my own part I can declare, that I have seen the small-pox (whether from inoculation, or the epidemic,) exist in every cutaneous affection, from the most severe itch, to the most triflmg her. petic affection, and that, so far from these affording any ob- struction to the regular progress of the variolous affection, those diseases, on the contrary, were either entirely cured or ^inderwent a very material change, and improvement But when we attend to what the Doctor states in the following paragraph, quoted above, the two affections not only lose all Lilarity, but vaccination is absolutely exposed to ridicule, and contempt, and the profession run some risk of being charged with corruption,' for seriously recommending, and enforcing, so weak, so trifling, and so uncertain a disease, as apreveitative of Jhe severe, dangerous, aud«xtensive affec (ion of small-pox.
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a small excoriation behind the ear — tzvo or three vesicles, even though of catarrhal ori- gin, on the hps, or about the nostrils — a few scurfy spots on any part of the body — and even those vesicles, and the subsequent state of the skin, that are produced by ex- ternal injury, (as I lately witnessed on vac- cinating a boy whose face was injured by the explosion of gunpowder), appear as ca- pable of producing irregularity in the pro- gress of the vaccine vesicle, as more exten- sive cuticular affections. Vaccination, when these maladies are present, seems to shew, that the whole surface of the skin is influen- ced at the same time, but in separate portions; for on one arm I often produce a perfect vaccine pock, and on the other, {mm the insertion of a portion of the same virus, one that is imperfect, and which would afford no security. Indeed, on the same arm, within the space of an inch from each other, there will often be this difference in the appear-
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ance of the pocks — one putting on the per- fect character, and the other deviating so widely, as to resemble more nearly that of an herpetic vesicle, accompanied with in- flammation, and commonly ending in a soft, amber-coloured, or blackish scab — and sometimes, especially if it be much dis- turbed by scratching, in ulceration. The probability then is, that the skin, at the point of insertion, is sound and in its natural state in the one instance, and diseased in the other, but not so, as I have before ob- served, as to be perceptible to the eye."
Besides the extracts we have already made from Dr Willan's treatise on this sub- ject, we shall now add the following :
*' W hilst we acknowledge that some who had been vaccinated in the preceding years, took the small-pox at this period, we have reason to congratulate ourselves that the number was so small, and that so few mis-
takes had been committed in a mode of practice entirely new.
" Several of those anomalies, or excep- tions to the general rule have occurred, but certainly not so often as was expected by those who considered the subject, from the first, dispassionately, nor have they been in sufficient number, to form any serious objection to the practice, founded on Dr Jenner's discovery *.
* In Dr Willan's collection of evidence, we meet with the following letter from Dr Cassells to Dr Binns : " I have vac- cinated above fifty children, one of which has, since gone through the small-pox caught by infection. When this child was inoculated for cow-pox, I had no reason to think it did not undergo the regular process of vaccination ; at the same time I will not assert that the disease was genuine. I profess my- self a friend to vaccination, although it should in some instan- ces be succeeded by small-pox, because I think it is clearly proved, that the vaccine poison, when absorbed into the hu- man system, has the power of rendering the poison of small- pox completely inert for so7ne years, and farther experience maj/ prove, that it will ultimately resist the action of vario- lous contagion. In my judgment, experience has not proy. cd that vaccination has triumphed over variolation, as many unsuccessful cases have been, from time to time, published from the minutes of the vaccine-pox institution, some of which I think impossible to disprove, particularly that of
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" The too zealous, and enthusiastic ad- vocates for the new inoculation, who ex- tended their views far beyond the limits of analogy or probability, have done no ser- vice to the cause.
" Imperfect vaccination, is not charac- terized by any uniform sign, or criterion, but exhibits, in different cases, very differ- ent appearances, as pustules, ulcerations, or vesicles of an irregular form. Inoculators are now generally acquainted with these appearances, but the chief nicety, and dif- . ficulty of vaccination is, in distinguishing from the genuine vesicle, some irregular ve- sicles, which have often been mistaken for it, and which do not wholly secure the con- stitution from the small-pox.
" Since the vaccine virus, compared with that of the small-pox, appears to be more
Sarah Waglin, by Dr Woodforde of Ansford, and AVilliam Rodman, by Mr Lawrey ; the former caught the casual cow- pox fourteen years ago, the latter fifteen years ago, and both have lately gone through the process of natural small*pox."
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delicate, and more liable to degenerate, or to fail in its operation from various causes,
several practitioners are of opinion, that the variolous is preferable to the vaccine inocu- lation, and that it may be conducted with equal safety. I need not at present reca- ' pitulate the advantages of vaccine inocula- tion, which thousands have attested. The salutary effects of this ])ractice, under the proper regulations, being fully established, should ive now desist from it, because it is found to require greater nicety and attention than many persons at first believed neces- sary? A very different conclusion ought surely to be drawn from failures, which were not so much the effects of accident, mistake, or oversight in the early inocula- tors, as of inexperience in the business they had undertaken. The right inference, from the mistakes or failures above stated, and from the nicetij of vaccine inoculation, is, that only those should be inoculators, who
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have had a sufficient education, and who have particularly attended to the subject of vac- cination *.
* Let us contrast this with the opinion of Dr Adams, who, it must be recollected, is physician to the Inoculation Hospital in London, and is also a friend to the practice of vaccination. He observes, " Another and much more important objection against vaccination has been drawn from the uncertainty of the process. It must be confessed, that the friends of vaccina- tion have been much too forward in accounting for supp6sed failures, by the imputation of an improper, or, as they often call it, an ignorant mode of conducting vaccination.
" That vaccination, like every thing else, requires cer- tain instructions, cannot be questioned. The disease is, however, so unijorm in its appearance, and so regular in its progress, as to be described, with more certainty, and conse- quently liable io fezoer errors, than any other with which we are acquainted."
The Doctor, too, in answer to a letter from Dr Hervcy, addressed to him by desire of the College of Physicians, rites thus : " Besides the prudent backwardness of most „i admitting novelties into practice, without ample proof of their utility, the causes which have prevented the general adoption of vaccination appear to me to have been, princi- pally, the mistaken zeal of its/newcZs. It ceuld not be ex- pectcd that men, who value themselves on their talents at in- vestigation, and feel conscious of their scrupulous adherence to truth, could patiently submit to be uncandidly treated for a scepticism, induced by events however accidental. When their accuracy was questioned, whilst they disregard- cd the assertions of their accusers, they became dil.gent m
w in
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** By an obvious collateral inference, we must be led to acknowledge the propriety,
collecting collateral evidence, and when their reasoning was ridiculed, instead of expressing only their doubts, they be- came parties in their own defence.
" Another inconvenience has arisen from a too great for- Ttardness at answering objections, before they were suffi- ciently matured ; hence, when variola appeared after vaccina- tion, the event was either denied^ or explained by so many minute causes, as were sufficient to frighten the ignorant, dis- gust the candid, and induce the prudent to avoid an experi- ment, the result of which Avas not sufficiently understood.
" A practice, at one ^/we represented as so simple, that the clergy, and females were invited to undertake it, became at once so mysterious, that only a chosen fewwcre said to un- derstand vaccination ; every untoward event was imputed to ignorance betzocen the true and spurious pustule ; to taking matter at too late a jjeriod; and to other causes still less sa. tisfactory.
" Had these uncertainties really existed, they would have been sufficient objections against a practice, the object of which is to secure the subject from a formidable disease, and from which, he might be secured by another, certainly less desirable, but well ascertained operation. But the truth IS, that vaccination is as simple as it was at Jirst announced ; that the true character of its vesicle is more certain than the local effect of any other morbid poison; that it is imjjcssible to confound it with a pustule of any kind ; and, that every difficulty might have been avoided, by requiring a correct register of the progress, from the period of insertion, to cicatrization, or for the most part, of perfect scabbing."
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of a strict examination of the persons ino- culated between the first of January 1799, and the first of January 1802, and the ne-^ cessity of reinoculation in every doubtful case. In cities, and large towns, where medical practitioners have easy access to their friends and patients, the examination might be performed without much trouble, and, if a little address were employed, without exciting much alarm.
" I wish that practitioners throughout the country would, by revising their pri- mary inoculations with a more experienced judgment, take care to ascertain the safety of those who have confided in them, and thus secure their own peace of mind ; for what would their feelings be, if the small- pox, casually conveyed, should prove fatal to any of the persons whom they first persuaded to make trial of the new inven- tion.
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" I shall perhaps be asked, whether I think that the variolous appearances *, in all the cases I have adduced (whether pro- duced from the effects of the variolous contagion, or from the introduction of the variolous virus by inoculation), were the consequences of imperfect vaccination^ — There is great difficulty in obtaining clear, and direct information on the subject, scarcely one private practitioner in ten, being able to produce any written note, or memorandum, of the appearances, or effects of the inoculation ; and even in public in- stitutions for gratuitous vaccination, the medical superintendents often lose the oj> portunity of ascertaining whether the ino- culation has proceeded rightly or not, be- cause the patients fail to attend at the pro- per times.
" When only a local effect is produced by inoculating with variolous matter, the
♦ Such as fever, rash and eruptions, &c. &c.
^18
constitution will be affected by the small- pox at a future period, as much as if no pustule had been formed *. This has been confirmed by numerous cases, some of which terminated fatally. If, in a few cases, per- fect vaccination does not prevent variolous fever and eruption, or inoculation, or expo- sure to contagion, it will at least place the persons who take the small-pox, in the same state, as those who have been inoculated with vaccine, and variolous matter about the same time, a state which has hitherto been wholly free from danger."
Let us now see what Mr Bryce says, who, it must be recollected, insists upon the perfect and unmodified antivariolous effi- cacy of vaccination.
* We have already observed, that in many of these cases, no objections nor doubts, appear to have been suggested at the period of vaccination, but seem only to have been brought into view after the occurrence of small-pox.
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" If the affection of cow-pox at the part inoculated has proceeded regularly through all its different stages, and if each stage has been clearly, and distinctly marked, we think ourselves authorised, from the united testi- mony of many eminent in the medical pro- fession, to conclude, that the general affec- tion, and consequently, the anti variolous pro- cess, has taken place in the constitution, even although no fever may have been de- tected *. But in many instances these dif- ferent stages are not regular, neither are
* Mr Bryce has the following observations on the cases of Nelson's children, " It seems somewhat extraordinary, however, that the cow-pox affection should have advanced with such regularity, and that, at the ver;y time of the erup- tive fever of small pox, tlie marks which have hitherto been regarded as denoting a constitutional affection in cow-pox, viz. the inflamed and hard areola, should also have been in perfection. In these two cases, and in several similar ones, which have since fallen under my observation, the constitu- tional affection from small-pox, must have followed that from the cow-pox in very close succession, or there must have been two diseases present, viz. the small.pox as a con- stitutional disease, and the cow-pox as a mere local affec- tion ! I"
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they distinctly marked ; and how far these irregularities may take place without frus- trating the purpose of the inoculation, and what may be the e.vact degree of the size of the vesicle, or of the surrounding inflamma- tion and hardness, which is to mark a con- stitutional affection, or to assure us that the an ti variolous process has been accomplish- ed, we 7iiiist confess we have no certain rule, to determine *. On this point, then, as-
*Mr George Bell also says, "All who have had sufTicient ex- perience in inoculating for the cow-pox, know, that there is no one certain criterion applicable to every case, by which it can be ascertained that the disease has pervaded the con- stitution.
" In judging from my own experience, as well as from conversation, and correspondence with others, and the per- usal of the best books upon the subject, my opinion is, that that when the cow-pox runs regularly through the stages I Lave stated, it never fails to preserve the patients from the contagion of small-pox. But it must be confessed, that some patients have been seized with the natural small-pox, or have received the infection by inoculation, who were supposed to have undergone the genuine vaccine disease.
" It is only by the most minute attention to every circum- stance of the disease, in all its stages, and to the combination and relation which all the appearances bear to each other, jthat a decisive opinion €an be formed."
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suredly, the most important to be ascertain- ed in the progress of the symptoms of cow- pox, every person is left to form his opi- nion, from a comparison in his own mind of the case under consideration, with what he may have read in the writings of au- thors, or with what he may have observed in other cases, which, to his own knowledge, had proved effectual. But it will be allowed, that a judgment thus formed must often be very inaccurate, and thus bring disappoint- ment, or tvorse, to all concerned, as well as discredit upon the inoculation.
" Since the foregoing pages were put to press, and while yet correcting the proofs of the present, I have had an opportunity of examining two cases, in which the small- pox have appeared, after the children had apparently undergone the cow-pox affection.
From the very first time that I had oc- casion to conduct the inoculation for cow- pox, the uncertainty of the desired change
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being operated upon the constitution, part- ly from the apparent shghtness of the affec- tion at the part inoculated, but chiefly, from a want of some well-defined mark, whereby to judge of a general affection, very forci- bly presented itself to my mind ; and, after having carefiilly attended to upwards of six hundred cases, which have fallen under my imrnediate care, I am thoroughly convin- ced, that some clear, and well-defined mark of a constitutional affection in cow-pox, dif- ferent from what has hitherto been observed by those who have written on this subject, is still to be regarded as the grand desidera- tum in conducting this new inoculation ; for, until this be established, our judgment of the efficacy of the cow-pox inoculation, in , preventing small-pox, must often be formed with doubt and anxiety, and top frequently frove ultimately erroneous.
" These distinctions, Of spurious cow-pox, and of irregular vesicles, many authors have
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endeavoured to establish, and to describe minutely, so as to be easily detected in prac- tice, but, in my opinion, with little success; for we still hear of many instances, in which the practitioner has been deceived in his opinion, concerning the safety of his patient, notwithstanding of the rules prescribed by those authors, for forming an opinion with precision on this point. And the ~ above quotation*, concerning the effects of irregu- lar vesicles on the constitution, shows the distinction made by Dr Willan, to be not only useless, but hurtful in practice, because, if these irregular vesicles effectually secure some constitutions, and only im.'perfectly se- cure others, how are we to distinguish whether our patient be perfectly or imper- fectly protected, and to what degree?
" These terms, therefore, appear to me fo be contrived, rather with a view of ex- plaining something not understood, than from
* See page 122.
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any correct observations made on the subject; terms contrived, under which the practitioner might sculk in case of failure, or mistake ; and the more nearly the descriptions of these said spurious and irregular vesicles are made to resemble the genuine vesicles, and the greater difficulty there is in distinguishing between them, the more effectually will this shield and protect those who use it *.
The introduction of the terms, " spuri- ous cow-pox," and, irregular vesicles pro- ducing imperfect vaccination," have, in my opinion, therefore, done much injury to the true interests of vaccination ; and I must here, for my own part, declare, that were I, in my practice of inoculation for the cow- pox, obliged to form my opinion concern- ing the presence and extent of the constitu- tional affection, and, consequently, con^ cerning the future safety of my patient, from the description of the affection as given by
* Here, Mr Bryce rises superior to every evasion.
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tlie authors who adopt these terms, such are the doubts which these descriptions would constantly create in my mind, that, however much I value this new inoculation, and few can value it more than I do, / would infinite' ly rather prefer at once, to inoculate with the small-pox."
Extracts, to the same purpose, might be readily obtained, sufficient to fill a volume • but, I apprehend, enough have been given to convince the reader, even, according to the professed advocates of the discover}^ not only of the urgent necessity for immediate investigation, before the practice can be farther recommended and adopted, but al- so, that in fact, there is but a straw-breadth betwixt us, and the moment a feeble and temporary power is admitted, every difficul- ty vanishes ; we are neither obliged to have recourse to the frivolous, and vexatious dis- tinctions of local, and constitutional, perfect, imperfect, and irregular vesicles; to the
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disgusting necessity of employing tests, for ascertaining the existence of the disease; and above all, to employ the contemptible eva- sions, of flea-bites and chicken-pox. On the contrarj^ every thing becomes consistent, harmonious, and intelligible, and the affec- tion appears in such characters, as easily to determine, even a very partial observer, what practice to adopt.
I have now discharged what seemed to me an indispensable duty, and I trust, it has appeared, that I have been anxious, ra- ther to address the judgment, than the feel- ings of my readers. While my own mind acquits me of any improper motives, I shall pay but little attention to the insinuations of others; it surely does not betray a want of candour, honesty, or contempt of self-in- terest, to contradict the opinions I have uni- formly given, and the assertions I have made for nearly nine years, and to render almost
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nugatory, twelve hundred cases, for which I have received remuneration. I am only sorry, that the sentiments I at present en- tertain of the vaccine practice, should appear to differ from those of so many of my pro- fessional brethren ; but I can conscientiouslv declare, that it will afford me the highest pleasure to find my apprehensions ground- less, and I will receive the greatest satisfac- tion, if what I have brought forward, shall only be the means of producing an investi- gation, which shall terminate in fixing vaccination, on an intelligible, efficacious, and practicable basis.
THE END.
Printed by G. Ramsay and Co. Ediuburgli, 1809.
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